Spousal Partner Abuse CEUs - Page 2

Working with Young Men Who Batter

Dean Peacock & Emily Rothman In 1995, domestic violence was recognized as one of the foremost public health concerns in the U.S. by Congress. Since 1997, violence committed by adolescents has also received significant attention due, in part, to a number of high profile school shootings (Office of Juvenile Justice and Delinquency Prevention, 1999). Teen dating violence, however, has received comparably little attention, despite its prevalence and the severity of its impact. Recognizing that this gap exists, researchers and practitioners have gradually begun to focus on adolescent males who perpetrate dating and family violence. As a result, juvenile batterer intervention programs have been developed in several jurisdictions across the United States. These programs attempt to hold young men who batter accountable for their violence and rehabilitate them whenever possible. No evaluations of these programs have been published, or to our knowledge conducted. Moreover, few efforts have been made to collect, summarize, evaluate and disseminate existing program methods or protocol. This article offers an overview of the nascent juvenile batterer intervention programs. It identifies risk factors for teen dating violence perpetration as described by the literature and considers the utility of these findings, describes efforts to prevent re-offenses by juvenile perpetrators of domestic violence, discusses several shortcomings inherent in post-crisis intervention, and outlines current challenges within the field. In addition, the authors draw upon research from related fields to posit possible future directions for research and intervention efforts. Prevalence A growing body of research indicates that dating and family violence is a leading cause of injury for women and girls. Lifetime prevalence of teen dating violence victimization among girls in the U.S. is estimated to be between 9 and 41% (Avery-Leaf, Cascardi, O'Leary & Cano, 1997; Silverman, Hathaway, Freedner, Aynalem & Tavares, 1999; Sugarman & Hotaling, 1986). Although research in the area of adolescent-to-parent violence is limited, several studies suggest that approximately 10% of adolescents aggress toward their parents each year (Cornell & Gelles, 1982; Peek, Fischer & Kidwell, 1985; Straus, Gelles & Steinmetz, 1980). Adolescent male violence against female family members is a concern of many practitioners, and is reported by battered women as frequently coinciding with violence from adult partners (Bancroft & Silverman, in press). Many (e.g. Carlson, 1990; Hotaling & Sugarman, 1986) theorize that men who abuse family members provide a powerful model for family violence to adolescent males.          Who are the boys most at risk for abusing and assaulting their dating partners? What can be done to prevent these adolescent batterers from becoming adult domestic violence offenders? While scientific inquiry into these topics is in its infancy, and intervention programs designed to address teen dating violence have yet to be established in most states, initial investigation and program development have taken place in select areas. Who are adolescent male perpetrators of dating violence? The profile of the adolescent male perpetrator of dating violence suggested by the literature is similar to the profile of other juvenile offenders. In short, teen boys who abuse their dating partners are more likely to have experienced child abuse or neglect (McCloskey, Figueredo & Koss, 1995; Wekerle & Wolfe, 1998; Wolfe, Werkele, Reitzel-Jaffe & Lefebvre, 1998), witnessed domestic violence (Hotaling & Sugarman, 1986), and to use alcohol or drugs (Cate, Henton, Koval, Christopher & Lloyd, 1982) than their non-abusive counterparts. In addition, several studies have established that adolescent males who abuse their dating partners are more likely to have sexist attitudes that support male domination over females (Follingstad, Rutledge, McNeil-Harlings & Polek, 1992; Henton, Cate, Koval, Lloyd & Christopher, 1983; Himelein, 1995; Koss & Dinero, 1989, Koss, Leonard, Beezley & Oros, 1985; Malamuth, Heavey, Barnes & Acker, 1995; Tontodonato & Crew, 1992) and are more likely to associate with peers that support these attitudes (Lavoie, Robitaille & Hebert, 2000; Roscoe & Callahan, 1985). It is important to note that most research conducted on juvenile perpetrators of domestic violence to date is based on non-representative samples; no studies have utilized samples that would enable generalization to all juvenile perpetrators of dating violence. Therefore, the studies reflect only the profile of those adolescents who come to the attention of researchers—i.e., boys who come into contact with the criminal justice system or who readily admit to perpetrating violence during interviews or surveys. It is possible that there are many adolescent males who perpetrate violence and abuse that don’t fit the established profile and will remain undetected by research. Moreover, it is critical to bear in mind that no study has established that any of the risk factors listed above (such as witnessing domestic violence) actually cause youth to perpetrate violence. Risk factors only reveal which characteristics or life experiences juvenile perpetrators are likely to share in common. They don’t provide us with answers to the question: “What is it that causes the boys to be violent?” Therefore, developing “profiles” or “prediction tools” based upon existing research is premature and could unfairly label adolescents. Practitioners who attempt to predict which adolescents are most dangerous based on available information run the risk of overestimating dangerousness for certain individuals and failing to identify those who are in fact dangerous. Investigation of resiliency or protective factors, in addition to research on the level of risk of individual offenders, may provide practitioners, survivors and policy-makers with more useful information (E. Gondolf, personal communication, June, 2000). Keeping in mind the limitations of “risk factor” research, we offer the following review of what is known about adolescent males who are violent towards dating partners, female family members and others. Parent-to-Child Violence: Maltreatment of children by parents is a consistent predictor of young males’ physically, sexually and verbally abusive behaviors (Wekerle & Wolfe, 1998; Wolfe et al., 1998; McCloskey et al., 1995) and later criminal behavior (Viemeroe, 1996). This evidence notwithstanding, it is also recognized that children who are maltreated by parents are not guaranteed to become adolescent or adult offenders; a significant proportion of children from abusive families are non-abusive to intimate partners (Widom, 1989). Adolescent males who are referred to programs for domestic violence perpetration should be screened for parent-to-child maltreatment and provided with services as needed. Witnessing Inter-parental Abuse: Many studies support the contention that young males who witness parental domestic violence are at increased risk for becoming abusive themselves in adult intimate relationships. Through a comprehensive review of family violence literature, Hotaling and Sugarman (1986) found that 88% of studies with adequate comparison groups revealed that witnessing parental violence was a significant predictor of adult violence against a female partner. Childhood observation of inter-parental abuse may also predict the development of attitudes that support violence against women (Silverman & Williamson, 1997; Stith & Farley, 1993). Practitioners are cautioned against approaching all adolescent males who witness family violence as potential offenders. Similarly, the literature does not support an assumption that all adolescent males who perpetrate domestic violence have witnessed inter-parental abuse. Rather, all adolescent males who witness domestic violence must receive appropriate support services and education regarding healthy relationships. All identified juvenile perpetrators of domestic violence should be screened for witnessing inter-parental abuse. Substance Use: Several studies have found that the perpetration of family and dating violence by adolescent males is strongly associated with alcohol consumption (Cate et al., 1982; Foo & Margolin, 1995; Makepeace, 1987; Malik, Sorenson & Aneshensel, 1997; O'Keefe, 1997; Symons, Lin & Gordon, 1998). No research has been conducted that establishes the effect of substance abuse intervention on teen dating violence perpetration rates. Many advocates predict that treating a juvenile perpetrator of domestic violence for substance abuse problems alone will not produce significant change in the perpetration of abusive behavior. Substance use and violence perpetration are often viewed as related, yet distinct, health problems that each require specialized intervention (Bennett, 1997). Sexist Attitudes: Several studies have found that adolescent males who possess attitudes legitimizing violence against female partners are more likely to report being physically violent toward dating partners (DeKeseredy & Kelly, 1993; Riggs & O'Leary, 1996; Silverman & Williamson, 1997; Smith, 1990; Stithe & Farley, 1993). Thus, intervention programs that fail to address perpetrators’ sexist attitudes may have a minimal effect. To date, there have been no evaluations of adolescent intervention programs that do or do not address sexism, nonetheless, advocates encourage practitioners to include education about sex-role stereotyping, and concepts of masculinity and femininity, in intervention programs on the basis of available research on adolescent attitudes. Peer Attitudes: At least three studies have found that having peers who support violence against women predicts one’s own dating violence behavior (DeKeseredy & Kelly, 1993; DeKeseredy & Schwartz, 1993; Silverman & Williamson, 1997). Based on this knowledge, some practitioners believe that encouraging juvenile perpetrators to form new peer relationships with non-violent and non-sexist males may reduce abuse perpetration. Current Methods Of Intervention Juvenile batterer intervention programs have emerged in the U.S. over the last decade. Most have developed in relative isolation from one another, despite the fact they often share similar philosophies. They have been developed by courts, survivor advocacy agencies, batterer intervention programs and community-based agencies that serve youth. As a result, the programs differ with regard to structure and methodology. As alternatives or complements to incarceration, such programs offer possible methods to re-educate young men about their relationships and their use of violence. Most juvenile batterer intervention programs utilize a psycho-educational group format and meet weekly for 1-2 hours. Intervention group activities may include discussions of healthy and unhealthy relationships, sex-role stereotyping, coping with anger or rejection, and the effect of alcohol or drug use on one’s behavior, among other topics. The atmosphere of groups is neither intimidating nor social; trained staff works to maintain a safe, encouraging, yet serious tone. Group cycles last from 12-52 weeks. Parents receive orientation information regarding the program and, in some communities, are involved in the intervention on an on-going basis. Intervention participants who re-offend may be expelled from the group or asked to re-start it, depending upon the program. In some communities, those who are expelled may face more severe penalties from a probation department or court. Table 1: Features of Some Juvenile Batterer Intervention Programs   Location Number of Youth Served Per year Ages Intervention Component Program Duration (in weeks) Referring Entity Expect Respect Austin, TX School Based 60 6-12 grade School groups. Individual & Family Available onsite 24 Middle and High Schools MOVE Youth Program SF, CA Agency based 30   12-21 Individual Group Family Siblings 52 minimum Juvenile Courts Mass DPH 10 Programs Mixed   150 13-17 Group 12 Juvenile Courts, Schools & DYS STEPUP Seattle, WA Comm. Centers 30-40   Individual Group Family 24 minimum Juvenile Courts, CBO’s Juvenile Batterer Intervention Programs: Challenges and Dilemmas Programs for adolescents who batter currently face a number of challenges and dilemmas, as do all new interventions. These challenges include public recognition of teen domestic violence as a phenomenon distinct from generalized violence; a dearth of culturally appropriate interventions and research; and partnering with a juvenile justice system perceived by many to suffer from pervasive racial and class biases. Recognizing teen batterers: Between 1997-1999, seven incidents of teen-perpetrated domestic violence received national attention in the U.S.—perhaps the most widely-publicized of these events being the shooting in Jonesboro, AK. In the wake of these tragedies, media posed questions about the cause of “youth violence” or “school violence,” but failed to emphasize that in all cases the shooters were male and the intended victims female (Sousa, 1999). In fact, the incidents might have been more appropriately and specifically classified as “violence against women or girls.” An inability to perceive violence perpetrated by adolescent males as similar to domestic violence perpetrated by adults may limit our capacity to alter their behavior. For many, it may be difficult to acknowledge that boys as young as eight or nine years old participate in “dating” relationships. As a result, in some cases abusive behavior may be dismissed or handled as though it were acceptable rough-housing. (For example, girls and boys may be told that if someone kicks or insults them, it is a sign of affection.) In order to offer victims of abuse consistent and comprehensive protection, and in order to provide young perpetrators with the services and intervention that they need, adults may be required to alter their own definitions of “dating.” Similarly, any incidents involving violence between adolescents should be assessed to determine if, and to what extent, dating or sexism was a motivational factor. Culturally appropriate intervention and research: Although men of color are over-represented in batterer intervention programs, there are few culturally specific intervention strategies and insufficient research on violence in communities of color (Richie, 1998; Williams, 1997). While research does not demonstrate conclusively that culturally specific programs have improved outcomes for adult batterers (Gondolf, 2000), some resarchers have found that men of color have higher completion rates when working with staff of similar ethnic backgrounds (O. Williams, personal communication, September, 2000). It is possible that these results would hold true for adolescent offenders in culturally-specific intervention programs as well. Despite the fact that very few outcome studies of culturally specific batterer intervention programs have been conducted, practitioners have expressed a need for the development, implementation and evaluation of culturally specific models (Carillo & Tello, 1998; Williams, 1997). Partnering with the juvenile justice system: The juvenile justice system has an important role to play in securing safety for victims and holding juvenile batterers accountable. In a number of jurisdictions, law enforcement agencies, probation departments and juvenile courts work with juvenile batterer intervention programs to monitor program compliance, enhance victim safety and to hold juvenile batterers accountable. Much work is still needed across the nation to establish a consistent juvenile justice response to teen dating violence. There are, however, considerable drawbacks to relying on the juvenile justice system as the primary agency of response to teen dating violence. By nature, the juvenile justice system provides a response only once violence has occurred. Other than the deterrent effect of holding batterers accountable for their violence after the fact, it does not seek to prevent dating violence. There are also significant risks associated with youth involvement in the juvenile justice system. According to Amnesty International, "use of incarceration in the United States Juvenile Justice System is a matter of grave concern because of its inherent risks to the physical and mental integrity of children, and its potential for negative influence rather than rehabilitation." (Amnesty International, 1998). In addition, recent research demonstrates that the juvenile justice system continues to suffer from pervasive racial bias (National Council on Crime and Delinquency, 2000). Efforts to respond to teen dating violence in communities of color will be hindered by the perception that the domestic violence movement relies uncritically on what is perceived as a racially biased system. Juvenile Batterer Intervention Programs: New Directions As the field of teen dating and family violence intervention becomes more sophisticated, stakeholders are increasingly exploring new strategies, identifying needs and attempting to build on lessons learned in related fields. Examples of these new developments include partnering with schools, drawing on the strengths of ecological approaches to violence, and promoting efforts that attempt to link post-crisis intervention with primary prevention. Partnering with school administrators and educators: While intervention with individual perpetrators of dating or family violence is essential, it as just as critical that social norms that support violence change. Educators have an enormous potential to affect the social environments in their classrooms and in their school-communities. School administrators have the power to design, promote and implement policies and curricular approaches that can significantly affect students’ attitudes and behavior. It is important that school personnel receive training on the topic of gender-based violence and are supported when they link existing literature or social studies themes to social norms regarding violence and gender (B. Rosenbluth, personal communication, November, 2000). Research: Creating policy or awarding funding to intervention programs in the absence of evaluation research potentially places victims at continued risk for abuse and may waste resources. It is imperative that long-term follow-up evaluation studies of juvenile intervention programs are conducted and that the results be widely disseminated. Moreover, those who develop programs should base the design of curricula and intervention components on data collected from program participants; optimal interventions will be created if the service population is more fully understood. Learning from related research: The last two decades have seen a proliferation in research and evaluation on violence prevention and intervention. While the bulk of the literature focuses specifically on youth violence, findings may be applied to dating and domestic violence intervention and prevention. In 1999, the Center for the Study and Prevention of Violence evaluated several violence prevention and intervention initiatives. Those that utilize ecological approaches were shown to have high success rates with violent juvenile offenders (Center for Prevention and Study of Violence, 2000). The factors associated with the success of ecological approaches are potentially instructive for the nascent efforts to rehabilitate and hold accountable young men who batter. Ecological approaches recognize that individuals often reflect the values of their families, communities, and societies, and that “effecting sustained change requires addressing the multiple problems of youth wherever they arise; in the family, the community, the health care and school systems" (Currie, 1998, p.105). Ecological approaches also recognize that treating offenders in isolation of their social environment is a "prescription for failure” (Currie, 1998, p.105). The evidence in favor of ecological approaches is supported by other studies that have found that involvement of the family seems necessary to effect sustained change (Henggeler, Melton, Smith, Hanley & Hutchinson, 1993; Tolan, Gorman-Smith, Huesmann & Zelli, 1997), and that community based efforts are more effective than institutional efforts (Tolan et al., 1997). Ecological Approaches: Some adult and youth batterer intervention programs have attempted to integrate ecological principles into batterer intervention programs. Common to some of these approaches is the recognition that each participant serves as an important point of access to the family, community members, including peers, and institutions such as the faith community, schools, other community based agencies, the juvenile and family courts and to youth employment agencies. This access makes it possible to enlist family, community members and institutions in holding perpetrators accountable and ensuring victim safety. In some cases, however, it is acknowledged that involving family members is not always appropriate—the safety of the young men who batter may be jeopardized if abusive parents are included in the approach. Unlike many intervention strategies that work to affect behavior change by focusing on perceived deficits, ecological approaches emphasize individual and community strengths and build on emerging understandings of individual resiliency and community assets. In Atlanta, the Men Stopping Violence (MSV) program attempts to affect the social ecology of adult program participants by involving their friends, and on occasions their sons, and by advocating for change across the broad range of institutions with which participants interact (S. Nuriddin, personal communication, April, 2000). Similarly, some juvenile batterer intervention programs have developed models that involve a wide range of stakeholders including city agencies, community based organizations and community members themselves. For instance, the MOVE Youth Program, a juvenile batterer intervention program based in San Francisco, CA, is implementing a model that involves family and community members in teen dating violence prevention (A. Silva, personal communication, May, 2000). In this way, ecological approaches such as those used by MSV and MOVE also serve as important opportunities for engaging in prevention, and in this way connect intervention and prevention efforts. The Case for Prevention: Studies indicate that "punitive, legalistic approaches" are unlikely to have much effect on youth violence unless they are integrated into policies that focus funding and efforts on prevention (Tolan, 2000). Domestic violence prevention campaigns have been pursued in health care settings, in schools and through the media, and show promise in changing attitudes towards the use of violence (Edleson, 2000). Important lessons can be drawn from related fields that have been effective in changing adolescent behaviors and attitudes, for example regarding teen pregnancy prevention and child abuse awareness (Daro & Cohn Donnelly, 2000). Prevention efforts may be enhanced through collaboration with related fields, such as child welfare and youth violence, and by developing connections with a range of agencies that serve youth. These partnerships could include linkages with mentoring programs, employment training sites, arts and recreation programs, rites of passage programs, and literacy and media literacy projects (National Advisory Council on Violence Against Women, 1999). Since lower education, lower-status jobs, and under-employment are all identified as probable risk factors for the perpetration of violence, effective prevention plans will need to address each of these, and the relationship between these potential risk factors and domestic violence should be further clarified by continuing research (Edleson, 2000; Kaufman Kantor & Jasinski, 1998). Prevention activities should also address peer behaviors and attitudes since these have been shown to affect boys’ choices about whether to use violence (Heise, 1998). Given the contemporary predisposition in favor of intervention and incapacitation, committing resources to prevention will require a shift in policy priorities (Tolan, 2000). Nevertheless, the returns on rigorously designed and well-implemented prevention may be significant in terms of money saved and lives enhanced. Conclusion The paper presented here offers a brief overview of the emerging field of working with adolescent perpetrators of domestic violence. The fact that there exists such a field, embryonic as it may be, is evidence of the increasing attention being paid to the devastating impact that intimate partner and family violence have on the lives of children and youth. While significant challenges remain, work being done to detect, deter and rehabilitate adolescent perpetrators represents an important step towards interrupting intergenerational cycles of violence and enhancing safety for victims.   Authors of this document:   Dean Peacock Emily Rothman, MS November 2001   The authors would like to thank Ed Gondolf, Oliver Williams and Larry Cohen for their thoughtful feedback and assistance in the development of this paper. The authors would also like to thank Jeff Edleson, Gita Mehrotra and Pam Baker at MINCAVA - Minnesota Center Against Violence & Abuse, University of Minnesota.   Citation: Peacock, D. & Rothman, E. (2001, November). Working With Young Men Who Batter: Current strategies and new directions. Harrisburg, PA: VAWnet, a project of the National Resource Center on Domestic Violence/Pennsylvania Coalition Against Domestic Violence. Retrieved 10-4-09, from: http://www.vawnet.org References   Amnesty International. (1998). And rights for all. Retrieved June 8, 2000, from http://www.rightsforallusa.org/info/report/r04.htm Avery-Leaf, S., Cascardi, M., O'Leary, K., & Cano, A. (1997). Efficacy of a dating violence prevention program on attitudes justifying aggression. Journal of Adolescent Health, 21, 11-17. Bancroft, L., & Silverman, J. (in press) The batterer as parent: Addressing the impact of domestic violence on family dynamics  Thousand Oaks, CA: Sage. Bennett, L. (1997). Substance abuse and woman abuse by male partners. Retrieved June 5, 2000, from University of Minnesota, Violence Against Women Online Resources, http://www.vaw.umn.edu/Vawnet/substanc.html Carillo, R., & Tello, J.(1998) Family violence and men of color: Healing the wounded male spirit. New York: Springer Publishing Company, Inc. Carlson, B. (1990). Adolescent observers of marital violence. Journal of Family Violence, 5(4), 285-299. Cate, R., Henton, J., Koval, J., Christopher, F., & Lloyd, S. (1982). Premarital abuse: A social psychological perspective. Journal of Marriage and the Family, 3(1), 71-90. Center for Prevention and Study of Violence (2000). Blueprints for violence prevention: Overview of multisystemic therapy. (n.d.). Retrieved May 31, 2000, from http://www.colorado.edu/cspv/blueprints/model/ten_Multisys.htm Cornell, C., & Gelles, R. (1982). Adolescent to parent violence. Urban and Social Change Review, 15(1), 8-14. Currie, E. (1998). Crime and punishment in america. New York: Henry Holt and Company, Inc. Daro, D., & Cohn Donnelly, A. (2000). Child abuse prevention: Accomplishments and challenges. Paper presented at the National Collaborative Violence Prevention Initiative Meeting hosted by the Family Violence Prevention Fund, San Francisco, CA, February, 15, 2000. DeKeseredy, W., & Kelly, K. (1993). Woman abuse in university and college dating relationships: The contribution of the ideology of familial patriarchy. Journal of Human Justice, 4(2), 25-52. DeKeseredy, W., & Schwartz, M. (1993). Male peer support and woman abuse: An expansion of DeKeseredy's model. Sociological Spectrum, 13, 393-413. Edleson, J. (2000). Primary prevention and domestic violence. Paper presented at the National Collaborative Violence Prevention Initiative Meeting hosted by the Family Violence Prevention Fund, February 15, 2000. Follingstad, D., Rutledge, L., McNeil-Harlings, K., & Polek, D. (1992). Factors related to physical violence in dating relationships. In E. C. Viano (Ed.), Intimate violence: Interdisciplinary perspectives (pp. 121-135). New York: Hemisphere. Foo, L., & Margolin, G. (1995). A multivariate investigation of dating aggression. Journal of Family Violence, 10(4), 351-377. Heise, L. (1998). Violence against women: An integrated, ecological framework. Violence Against Women, 4, 262-290. Henggeler, S., Melton, G., Smith, L., Hanley, J., & Hutchison, C. (1993). Assessing violent offending in serious juvenile offenders. Journal of Abnormal Child Psychology, 21(3), 233-243. Henon, J., Cate, R., Koval, J., Lloyd, S., & Christopher, S. (1983). Romance and violence in dating relationships. Journal of Family Issues, 4, 467-482. Himelein, M. (1995). Risk factors for sexual victimization in dating: A longitudinal study of college women. Psychology of Women Quarterly, 19, 31-48. Hotaling, G., & Sugarman, D. (1986). An analysis of risk markers in husband to wife violence: The current state of knowledge. Violence and Victims, 1, 101-124. Kaufman Kantor, G., & Jasinski, J. (1998). Dynamics and risk factors in partner violence. Thousand Oaks, CA: Sage. Koss, M., & Dinero, T. (1989). Discriminant analysis of risk factors for sexual victimization among a national sample of college women. Journal of Consulting and Clinical Psychology, 50, 455-457. Koss, M., Leonard, K., Beezley, D., & Oros, C. (1985). Nonstranger sexual aggression: A discriminant analysis of the psychological characteristics of undetected offenders. Sex Roles, 12, 981-992. Lavoie, F., Robitaille, L., & Hebert, M. (2000). Teen dating relationships and regression. Violence Against Women, 6(1), 6-36. Makepeace, J. (1987). Social factors in victim offender differences in courtship violence. Family Relations, 36(1), 87-91. Malamuth, N., D, L., Heavey, C., Barnes, G., & Acker, M. (1995). Using the confluence of sexual aggression to predict men's conflict with women: A 10-year follow-up study. Journal of Personality and Social Psychology, 60, 353-369. Malik, S., Sorenson, S., & Aneshensel, C. (1997). Community and dating violence among adolescents: Perpetration and victimization. Journal of Adolescent Health, 21, 291-302. McCloskey, L., Figueredo, A., & Koss, M. (1995). The effects of systemic family violence on children's mental health. Child Development, 66(5), 1239-1261. National Advisory Council on Violence Against Women (1999). Prevention and early intervention task force . National Advisory Council on Violence Against Women. National Council on Crime and Deliquency (2000). And Justice for Some. Retrieved May 17, 2000, from http://www.buildingblocksforyouth.org/justiceforsome/ Office of Juvenile Justice and Delinquency Prevention (1999). Report to congress on juvenile violence research. (NCJ publication 176976). Washington, DC: US Government Printing Office. O'Keefe, M. (1997). Predictors of dating violence among high school students. Journal of Interpersonal Violence, 12(4), 546-568. Peek, C., Fischer, J., & Kidwell, J. (1985). Teenage violence towards parents: a neglected dimension of family violence. Journal of Marriage and the Family, 47(4), 1051-1058. Riggs, D., & O'Leary, K. (1996). Aggression between heterosexual dating partners. Journal of Interpersonal Violence, 11, 519-540. Richie, B. (1998). Defining popular culture interventions. Paper presented at the Institute on Domestic Violence in the African American Community, Chicago, IL. Roscoe, B., & Callahan, J. (1985). Adolescents' self-report of violence in families and dating relations. Adolescence, 20, 545-553. Silverman, J., Hathaway, J., Freedner, N., Aynalem, G., & Tavares, B. (1999). Prevalence and associated health risk behaviors of dating violence among high school females: Findings from the 1997 Massachusetts youth risk behavior survey. Paper presented at the 126th Annual Meeting of the American Public Health Association, Chicago, IL. Silverman, J., & Williamson, G. (1997). Social ecology and entitlement involved in heterosexual battering by college males: Contributions of family and peers. Victims and Violence, 12(2), 147-164. Smith, M. (1990). Patriarchal ideology and wife-beating: A test of a feminist hypothesis. Violence and Victims, 5, 257-273. Sousa, C. A. (1999). Teen dating violence: The hidden epidemic. Family and Conciliation Courts Review, 37(3), 356-374. Stith, S., & Farley, S. (1993). A predictive model of male spousal violence. Journal of Family Violence, 8, 183-201. Straus, M., Gelles, R., & Steinmetz, S. (1980). Behind closed doors: Violence in the American family. Garden City, NY: Anchor Press. Sugarman, D. B., & Hotaling, G. T. (1989). Dating violence: Prevalence, context, and risk markers. In M. A. E. S. Pirog-Good, Jan E. (Ed); et al (Ed.), Violence in dating relationships: Emerging social issues. (pp. 291 pp). New York, NY: Praeger Publishers. Symons, R., Lin, K.-H., & Gordon, L. (1998). Socialization in the family of origin and male dating violence: A prospective study. Journal of Marriage and the Family, 60(2), 467-478. Tolan, P. (2000). Youth violence prevention. Paper presented at the National Collaborative Violence Prevention Initiative Meeting. Tolan, P., Gorman-Smith, D., Huesmann, L., & Zelli, A. (1997). Assessment of family relationship characteristics: A measure to explain risk for antisocial behavior and depression in youth. Psychological Assessment, 9, 212-223. Tontodonato, P., & Crew, BK. (1992). Dating violence, social learning theory, and gender: A multivariate analysis. Violence and Victims, 7, 3-14. Viemeroe, V. (1996). Factors in childhood that predict later criminal behavior. Aggressive Behavior, 22(2), 87-97. Wekerle, C., & Wolfe, D. (1998). The role of child maltreatment and attachment style in adolescent relationship violence. Development & Psychopathology, 10(3), 571-586. Widom, C. (1989). The cycle of violence. Science, 244(4901), 160-166. Williams, O. (1997). Partner abuse in the Black community: Culturally specific prevention and treatment models. Paper presented at the Institute on Domestic Violence in the African American Community (proceedings), Atlanta, GA, December 4, 1997. Wolfe, D., Wekerle, C., Reitzel-Jaffe, D., & Lefebvre, L. (1998). Factors associated with abusive relationships among maltreated and nonmaltreated youth. Development & Psychopathology, 10(1), 61-85. Working with Men to Prevent Violence Against Women: An Overview (Part One) Alan D. Berkowitz With contributions from David Mathews  There is a growing awareness that men, in partnership with women, can play a significant role in ending violence against women.   This has led to an increase in programs and activities that focus on men's roles in violence prevention.   Men should take responsibility for preventing violence against women because of the untold harm it causes to women in men's lives and the ways in which it directly hurts men.   Violence against women hurts men when it results in women being afraid of or suspicious of men due to fear of potential victimization and when it perpetuates negative stereotypes of men based on the actions of a few.   The behaviors and attitudes that cause violence against women may also be a cause of men being violent towards other men.   These same behaviors and attitudes may also keep men from having close and meaningful relationships with each other.   Finally, while only a minority of men are violent, all men can have an influence on the culture and environment that allows other men to be perpetrators.   For example, men can refuse to be bystanders to other men's violent behavior. For all of these reasons men have a stake in ending violence against women.   To do this, men must accept and examine their own potential for violence and take a stand against the violence of other men.   In recent years, a number of authors have argued persuasively that men need to take responsibility for preventing men's violence against women, both in the United States (Berkowitz, 2002a; Funk, 1993; Katz, 1995; Kilmartin, 2001; Kivel, 1992), and internationally (Brienes, Connell, & Eide, 2000; Flood, 2001, 2003; INSTRAW, 2002; Kaufman, 2001). This paper provides a brief overview of what is known about effective strategies for involving men in violence prevention efforts from the perspective of men who are recipients of anti-violence programs as well as from the men who provide them.   It defines the term "prevention" for men's violence against women, reviews best practices for involving men and for tailoring programs (for men in general and for particular groups of men) and, in Part Two, offers examples of prevention program formats and pedagogy.   These examples are provided to illustrate best practices rather than to describe specific programs, as this review is not intended to be exhaustive or comprehensive of all violence prevention efforts involving men.   Finally, in order to be useful to practitioners and educators the paper provides references to websites containing information about men's anti-violence organizations and programs.   While the conclusions and trends noted here are applicable to the prevention of all forms of men's violence against women, the preponderance of literature cited is from the rape prevention field where there has been more research conducted on this subject. Defining Men's Roles in Prevention Men can prevent violence against women by not personally engaging in violence, by intervening against the violence of other men, and by addressing the root causes of violence.   This broad definition provides roles for all men in preventing violence against women.   Men's involvement can take the form of primary or universal prevention (directed at all men, including those who do not appear to be at risk of committing violence and those who may be at risk for continuing a pattern of violence), through secondary or selective prevention (directed at men who are at-risk for committing violence), and/or through more intensive tertiary or indicated prevention (with men who have already been violent).   For violence prevention these distinctions may be somewhat artificial because it can be argued that all men are at risk for perpetration by virtue of their socialization as men (Hong, 2000; Kaufman, 1985), because men can commit violence without defining it as such, and because men who have been violent can successfully participate in programs to prevent other men's violence.   "Prevention" is defined here as any program or activity that reduces or prevents future violence against women by men.   Programs for men who already have a documented history of violence against women, such as batterer's or perpetrator treatment programs, will not be discussed here. Prevention programs can take the form of one session, a series of sessions or ongoing interactive educational workshops, leadership training, social marketing and social norms media campaigns (defined in Part Two of this paper), or through participation in one-time or ongoing public events.   These may focus directly on the issue of violence or on its specific forms (for example, sexual assault, domestic violence, dating violence and/or harassment, and stalking), or indirectly through men's involvement in consciousness raising, fatherhood and/or skill-building programs that foster attitudes and behaviors that may protect against violence, or by providing healthy resocialization experiences about what it means to be a healthy, nonviolent man.   In its broadest definition, violence prevention for men includes any activity that addresses the root causes of men's violence including social and structural causes as well as men's gender role socialization and men's sexism. Among men's violence prevention programs those for school-aged boys have tended to focus on issues of sexual harassment and dating violence, those for college age men have tended to focus on sexual assault, and those for men not in college or older have tended to focus on domestic violence in longer-term partnerships.   In actuality it is important for all men to be involved in the prevention of all forms of violence against women, even when it may be developmentally or strategically appropriate to foster this involvement by focusing initially on one form of men's violence. What Works in Men's Violence Prevention? Due to evaluation literature that is limited in scope, it is difficult to assess the effectiveness of violence prevention programs for men.   For example, most prevention program assessments measure changes in attitudes that are associated with a proclivity to be violent rather than actual violent behavior.   Reviews of the literature suggest that sexual assault prevention programs for college men can be effective in improving attitudes that may put men at-risk for committing violence against women, although these attitudinal changes are often limited to periods of a few months (Brecklin & Forde, 2001; Breitenbecher, 2000; Lonsway, 1996; Schewe, 2002). In contrast, programs that focus only on providing information have not been found to be effective (Schewe, 2002). Among pre-college aged males, dating violence and harassment prevention programs offered to mixed gender groups in school settings can result in both attitude and behavior change for a few months or longer (Avery-Leaf & Cascardi, 2002).   Despite the limited research, there is an emerging consensus regarding what constitutes effective violence prevention for men.   Violence prevention programs that have been found effective in evaluation studies tend to share one or more of the assumptions listed below.   Practitioners who work with men to prevent violence have also concluded that effective violence prevention programs for men share some or all of these assumptions: •  Men must assume responsibility for preventing men's violence against women. •  Men need to be approached as partners in solving the problem rather than as perpetrators. •  Workshops and other activities are more effective when conducted by peers in small, all-male groups because of the immense influence that men have on each other and because of the safety all-male groups can provide. •  Discussions should be interactive and encourage honest sharing of feelings, ideas, and beliefs. •  Opportunities should be created to discuss and critique prevailing understandings of masculinity and men's discomfort with them, as well as men's misperceptions of other men's attitudes and behavior. •  Positive anti-violence values and healthy aspects of men's experience should be strengthened, including teaching men to intervene in other men's behavior. •  Work with men must be in collaboration with and accountable to women working as advocates, educators, and prevention specialists. What is the Logic of these Assumptions?   First, research and experience have shown that putting men on the defensive or using blame is not effective and can even result in negative outcomes.   Thus, in Lonsway's review of the literature she stated:   "although educational programs challenging rape culture do require confrontation of established ideologies, such interventions do not necessitate a style of personal confrontation "   (Italics added, 1996, p. 250).   Thus, men should take responsibility for acting as perpetrators and bystanders of violence and the best way to accomplish this is to encourage men to be partners in solving the problem rather than by criticizing or blaming men (Berkowitz, 2002a; Men Can Stop Rape, 2000; Schewe, 2002).   Most men are not coercive or opportunistic, do not want to victimize others, and are willing to be part of the solution to ending sexual assault.   (In contrast, while men who are predatory or who have a history of perpetration may benefit from exposure to some education and prevention programs, more intensive treatment is likely required for these men to change previous patterns of perpetration). The majority of men may already hold attitudes that can be strengthened to prevent and reduce violence and encourage men to intervene with other men.   For example, research has demonstrated that most men are uncomfortable with how they have been taught to be men, including how to be in relationship with women, homophobia, heterosexism, and emotional expression, and that they are uncomfortable with the sexism and inappropriate behavior of other men (Berkowitz, 2003; 2004).   Because many men already feel blamed and are on the defensive about the issue of men's violence (even when this defensiveness is misplaced), effective approaches create a learning environment that can surface the positive attitudes and behaviors that allow men to be part of the solution.   This can be accomplished in the context of a safe, nonjudgmental atmosphere for open discussion and dialogue in which men can discuss feelings about relationships, sexuality, aggression, etc. and share discomfort about the behavior of other men. What Types of Discussions are Effective?   Literature reviews have suggested that the quality and interactive nature of the discussion may be more important than the format in which it is presented (Breitenbecher, 2000; Lonsway, 1996), a dimension that Davis (2000) has called "program process."   Because men are influenced by other men and by what men think is true about other men, this influence can be positively channeled in all-male groups.   Thus, effective violence prevention for men acknowledges the important influence that male peer groups have on men's actions (Schwartz & DeKeseredy, 1997), corrects misperceptions that men have about each other's attitudes and behavior (Berkowitz, 2002a), and channels this influence towards positive change. The common element in successful prevention programs for men is the opportunity to participate in an experience where men are encouraged to honestly share real feelings and concerns about issues of masculinity and men's violence.   The opportunity for men to hear the attitudes and views of other men is powerful, especially because it empowers men who want to help and provides them with visible allies.   This strategy encourages the majority of men to take the necessary steps to avoid perpetrating and to confront the inappropriate behavior of male peers.   Are All Male or Mixed Gender Programs More Effective?   Research suggests that these goals can be accomplished most effectively with male facilitators in all-male groups.   For example, Brecklin and Forde (2001) conducted a comprehensive meta-analysis of forty-three college rape prevention program evaluations and concluded that both men and women experienced more beneficial change in single-gender groups than in mixed-gender groups.   This was also the conclusion reached in five other literature reviews of rape prevention programs that all recommended that rape prevention programs be conducted in separate-gender groups when possible (Breitenbecher, 2000; Gidycz, Dowall & Marioni, 2002; Lonsway, 1996; Schewe, 2002; Yeater & Donohue, 1999). While there are advantages to programs facilitated by men, skilled female facilitators can also work very effectively with men.   Women working with men need to be aware that men may view their leadership as reinforcing the assumption that violence prevention is a "women's issue" not relevant to men and must also find ways to prevent participants from attributing honest dialogue simply to the presence of a female.   It is also beneficial for men to see women and men co-facilitating in a respectful partnership.   Examples of programs for men that have been developed and led by women include those by Hong (2000) and Mahlstedt (1999).   One of the main arguments for separate gender workshops is that the goals for violence prevention are different for men and women (Gidycz, Dowdall, & Marioni, 2002; Schewe, 2002).   Despite this being true in some settings, it may be necessary or more appropriate to offer violence prevention in mixed groups. Trainers must still take into account the gender differences that make such separation desirable, avoid the polarization that can occur in mixed-gender groups, avoid potential victim-blaming, not give information about victim-risk that could be useful to perpetrators, and avoid approaches that are blaming of men (Schewe, 2002).   While mixed gender workshops have been evaluated as successful with boys in school settings, these programs have not been compared with similar programs offered in all-male settings (see Avery-Leaf & Cascardi, 2002 for an excellent review of this literature Partnerships with Women and Accountability to Women.   Attention to men's roles in preventing violence against women is only possible because of the decades of tireless work and sacrifice by female victim advocates, social activists, researchers, academicians, survivors, and leaders.   These courageous women have successfully challenged society to take notice of this problem and to begin to fund efforts to solve it.   Men's work to end violence against women must include recognition of this leadership and must never be in competition with or at the expense of women's efforts.   Thus, prevention programs for men should be developed to exist alongside of victim advocacy, legal and policy initiatives, academic research, rape crisis and domestic violence services, and educational programs for women.   Male anti-violence educators must recognize that we are accountable to the women who are the victims of the violence we hope to end, and must work to create effective collaborative partnerships and alliances that provide a role for women in men's programs (Flood, 2003).   To do this requires an understanding and exploration of men's privilege, sexism, and other biases, and an openness to learning from women and to working with them as allies. Challenges to Men's Involvement.   Finally, it is important to acknowledge that there are many challenges and barriers for men who do this work.   Men who work to end violence against women are challenging the dominant culture and the understandings of masculinity that maintain it.   Thus, male activists are often met with suspicion, homophobia and other questions about their "masculinity." Men and women who feel threatened by this work often discredit male activists efforts and persons (Flood, 2003; Stillerman, 1998).   At the same time many men are grateful for the example set by male activists and for modeling a different way of being male.   Men who do this work are also frequently and unfairly given more credit for their efforts than women who do similar work (Flood, 2001).   Men engaged in violence prevention need to personally recognize these challenges and take responsibility to change these dynamics both personally and professionally. Cultural Issues and Masculinities While men in North America may share some common socialization experiences and definitions of what it means to be male, there are also important differences in terms of race, ethnicity, social class, sexual orientation, religion, and other identities that must be addressed in violence prevention efforts.   In addition, there are cultural differences regarding the appropriate context for prevention including how violence should be addressed.   Currently there is extensive literature documenting the need for culturally relevant and tailored programs in medical, psychological, and public health literatures, along with evidence for the ineffectiveness of approaches derived from dominant groups or paradigms.   Providing culturally competent programming should not be considered optional, but is a necessity for effectiveness.   "Relevance" is a critical component of program success. It has been determined to be an important component of effective prevention programs and is discussed further in Part Two of this paper.   Because men from different identities have different experiences, relevant programming must address these differences, including experiences of racism among men of color, of homophobia for gay, bisexual and/or transgender men, the effects of economic inequalities for working class and poor men, and the cultural context for violence prevention within different communities.   As with every other issue, there is a danger of imposing definitions and understandings from more established violence prevention efforts (which, like the larger culture, is predominantly white and middle class) upon other cultures and communities. An example of the importance of culturally relevant programs comes from research on the differential impact of programs on men from different racial backgrounds.   In one study, a generic race-neutral program was effective for European heritage men but not men of color, while a modified program with a co-presenter of color and relevant information (including statistics on violence in ethnic communities and dispelling of ethnically based rape myths) were effective for both groups (Heppner, Neville, Smith, Kivlighan, & Gershuny, 1999).   In other research conducted on perpetrators from different ethnic backgrounds, differences were found in personality characteristics and motivations for perpetration that may have important implications for designing culturally sensitive prevention programs for men (Hall, Sue, Narang, & Lilly, 2000; Kim & Zane, 2004). Violence prevention efforts need to acknowledge these kinds of differences and also correct stereotypes and myths about the prevalence of violence among different groups of men.   Finally, men from different cultural groups have different experiences with the educational and criminal justice systems that may influence receptivity to violence prevention.   Violence prevention efforts that are community based, sensitive to ethnic and class issues, and accountable to the larger community have been developed in many communities and show promise. All of the above strongly suggest the critical importance of developing programs that are either tailored to the needs of a particular group, or conducted in a way that is inclusive and welcoming of all backgrounds.   A critical oversight is the lack of research examining the needs of gay, bisexual and transgendered men with respect to violence prevention programming.   Summary In recent years there has been expanded interest in developing programs and strategies that focus on men's responsibility for ending violence against women.   These programs create a safe environment for men to discuss and challenge each other with respect to information and attitudes about men's violence.   The literature suggests that these programs can produce short-term change in men's attitudes that are associated with a proclivity for violence, encourage men to intervene against the behavior of other men, and in some cases reduce men's future violence.   As these programs become more popular and as more men take leadership on this issue we are hopeful that the epidemic of men's violence against women will be significantly reduced and that all of our relationships will come closer to embodying ideals of respect, mutual empowerment, growth, and co-creation. Note: Portions of this review were adapted from "Fostering Men's Responsibility for Preventing Sexual Assault" and "Working with Men to Prevent Sexual Assault," both written by the author in 2002. Author of this document: Alan David Berkowitz, Ph.D. Independent Consultant Founder and Editor of The Report on Social Norms Consultant: Dave Mathews, PsyD, LICSW Director of Therapy Domestic Abuse Project 204 W. Franklin Avenue Minneapolis, MN 55404 dmathews@mndap.org Citation: Berkowitz, A. (2004, October). Working With Men to Prevent Violence: An Overview (Part One). Harrisburg, PA: VAWnet, a project of the National Resource Center on Domestic Violence/Pennsylvania Coalition Against Domestic Violence. Retrieved 10-4-09, from: http://www.vawnet.org References Avery-Leaf, S. & Cascardi, M. (2002). Dating violence education: Prevention and early intervention strategies. In P. Schewe (Ed.), Preventing violence in relationships (pp.79-106). Washington, DC: American Psychological Association. Berkowitz, A.D. (2002a). Fostering men's responsibility for preventing sexual assault. In P. Schewe (Ed.), Preventing violence in relationships (pp.163-196). Washington, DC: American Psychological Association. Berkowitz, A.D. (2002b, Spring/Summer).   Working with Men to Prevent Sexual Assault. Newsletter of the National Sexual Violence Resource Center, 2, 4-6. Berkowitz, A.D. (2003). Applications of social norms theory to other health and social justice issues. In H. Wesley Perkins (Ed.), The social norms approach to prevention (pp.259-279). San Francisco: Jossey Bass. Berkowitz, A.D. (2004). The social norms approach: Theory, research and annotated bibliography . Retrieved July 28, 2004 from www.edc.org/hec/socialnorms/ Brecklin, L.R. & Forde, D.R. (2001). A meta-analysis of rape education programs. Violence and Victims,16 , 303-321. Breitenbecher, K.H. (2000). Sexual assault on college campuses: Is an ounce of prevention enough? Applied and Preventive Psychology, 9 , 23-52. Breines, I., Connell, R., & Eide, I. (2000). (Eds.) Male roles, masculinities and violence: A culture of peace perspective. Paris: UNESCO Publishing. Davis, T.L. (2000). Programming for men to reduce sexual violence. In D. Liddel & J. Lund (Eds.), Powerful programs for student learning: Approaches that make a difference: New Directions for Student Services No. 90 (pp. 79-89) . San Fransico, Jossey-Bass. Flood, M. (2001). Men's collective anti-violence activism and the struggle for gender justice. Violence against Women and the Culture of Masculinity Development, 44 (3), 42-47. Flood, M. (2003). Men's collective struggles for gender justice: The case of anti-violence activism.   In M. Kimmel, J. Hearn, & R.W. Connell (Eds.), The handbook of studies on men and masculinities (pp.458-466) . Thousand Oaks, CA: Sage. Funk, R.E. (1993). Stopping rape: A challenge for men. Philadelphia: New Society Publishers. Gidycz, C.A., Dowdall, C.L., & Marioni, N.L. (2002). Interventions to prevent rape and sexual assault. In J. Petrak & B. Hedge (Eds.), The trauma of adult sexual assault: Treatment, prevention, and policy (pp. 235-260). NY: J. Wiley & Sons. Hall, G.C.N., Sue, S., Narang, D.S. & Lilly, R.S. (2000). Culture-specific models of men's sexual aggression: Intra- and interpersonal determinants. Cultural Diversity and Ethnic Minority Psychology, 6 (3), 252-267. Heppner, M.J., Neville, H.A., Smith K., Kivlighan, D.M., & Gershuny, B.S., (1999). Examining immediate and long-term efficacy of rape prevention programming with racially diverse college men. Journal of Counseling Psychology, 46 (1), 16-26. Hong, L. (2000). Towards a transformed approach to prevention: Breaking the link between masculinity and violence. Journal of American College Health, 48, 269-279. INSTRAW. (2002). Partners in change: Working with men to end gender-based violence . Santo Domingo, Dominican Republic: United Nations International Research and Training Institute for the Advancement of Women (INSTRAW). Kaufman, M. (1985). The construction of masculinity and the triad of men's violence. In M. Kaufman, (Ed.), Beyond patriarchy: Essays by men on pleasure, power and change (pp.1-29). Toronto: Oxford University Press. Kaufman, M. (2001). Building a movement of men working to end violence against women. Violence against Women and the Culture of Masculinity Development, 44 (3), 9-14. Katz, J. (1995). Reconstructing masculinity in the locker room: The mentors in violence prevention project. Harvard Educational Review, 65 (2), 163-174. Kilmartin, C.T. (2001). Sexual assault in context: Teaching college men about gender . Holmes Beach, FL: Learning Publications. Kim, I.J. & Zane, N.W.S. (2004). Ethnic and cultural variations in anger regulation and attachment patterns among Korean American and European American batterers. Cultural Diversity and Ethnic Minority Psychology, 10 (2), 151-168. Kivel, P. (1992). Men's work: How to stop the violence that tears our lives apart . Center City, MN: Hazelden. Lonsway, K.A. (1996). Preventing acquaintance rape through education: What do we know? Psychology of Women Quarterly , 20, 229-265. Mahlstedt, D. (1999). Men's work: Fraternity brothers stopping violence against women . New York: Insight Media. Men Can Stop Rape (MCSR) (2000). Speaking with Men about sexism and sexual violence: Training packet. Washington, DC: Author. Schewe, P.A. (2002). Guidelines for developing rape prevention and risk reduction interventions. In P. Schewe (Ed.), Preventing violence in relationships (pp.107-136). Washington, DC: American Psychological Association. Schwartz, M.D. & DeKeseredy, W.S. (1997). Sexual assault on campus: The role of male peer support. Thousand Oaks, CA: Sage Publications. Stillerman, J. (1998, October). Gender offenders: Perceptions of men doing anti-rape education. Paper presented at the Eighth International Conference on Sexual Assault and Harassment on Campus. Orlando, FL. Yeater, E.A. & O'Donohue, W. (1999). Sexual assault prevention programs: Current issues, future directions, and the potential efficacy of interventions with women. Clinical Psychology Review, 19 (7), 739-771. Working with Men to Prevent Violence Against Women: Program Modalities and Formats (Part Two) Alan D. Berkowitz With contributions from David Mathews  In Part One of this paper an overview was provided of men's role in prevention along with effective strategies for ending men's violence against women, and the importance of creating culturally relevant programs that address all of men's identities was presented.   The discussion is continued in this document by providing an overview of best practices in prevention, the content and format of men's prevention programs, and an overview of different program philosophies or pedagogies. It is a challenge to classify and summarize the many different types of violence prevention efforts that have been developed for men in recent years.   One-way to conceptually organize and describe them is in terms of:   1) program content; 2) program format (how the information is provided and delivered), and; 3) program philosophy or pedagogy.   In addition, extensive research within the prevention field regarding program effectiveness has identified best practices that can be applied to programs on all three of these dimensions.   These topics are reviewed below, beginning with best practices. Best Practices in Prevention The prevention literature suggests that effective prevention programs have a number of characteristics that are independent of particular issues or topical areas.   In particular, effective prevention programs are comprehensive, intensive, relevant to the audience, and deliver positive messages.   (For a more detailed discussion of these areas with respect to rape prevention see Berkowitz, 2001.) Comprehensiveness.   Comprehensiveness addresses who participates in the intervention.   In a comprehensive program all relevant community members or systems are involved and have clearly defined roles and responsibilities.   Linking activities that are normally separate and disconnected can create positive synergy and result in activities that are more effective in combination than alone.   A comprehensive program views the target population as the whole community and emphasizes creating meaningful connections with colleagues.   This can foster awareness of what others are doing, develop a common prevention framework, and provide information and messages that are mutually reinforcing, integrated and synergistic. Within the domestic violence prevention movement, comprehensiveness has been encouraged through the development of coordinated community responses to men's violence and its prevention (Pence, 1999).   Intensiveness.   Intensiveness is a function of what happens within a program activity.   Programs should offer learning opportunities that are interactive and sustained over time with active rather than passive participation.   In general, interactive interventions are more effective than those that require only passive participation (Lonsway, 1996; Schewe, 2002).   Interactive programs that are sustained over time and which have multiple points of contact with reinforcing messages are stronger than programs that occur at one point in time only.   As noted earlier, providing meaningful interactions between men that foster change is a critical element of successful violence prevention programs. Relevance .   Relevant programs are tailored to the age, community, culture, and socioeconomic status of the recipients and take into consideration an individual's peer group experience.   Creating relevant programs requires acknowledging the special needs and concerns of different communities and affinity groups.   These programs are stronger when group-specific information is used in place of generic statistics (Schewe, 2002).   Relevance can be accomplished by designing programs for general audiences that are inclusive and acknowledge participant differences, or by designing special programs for particular audiences.   Relevant programs pay attention to the culture of the problem, the culture of the service or message delivery system, and the culture of the target population (Berkowitz, 2003).   Differences in these three cultures must be addressed in the design of programs.   Carillo and Tello (1998) provide an excellent example of the issues involved in designing culturally relevant programs for men of color from a variety of ethnic backgrounds.   Part One of this paper contains an extensive discussion of relevance from the perspective of developing culturally inclusive programs for men. Positive messages should build on men's values and predisposition to act in a positive manner.   Men are more receptive to positive messages outlining what can be done than to negative messages that promote fear or blame.   To design a program that incorporates these elements may seem like a daunting task.   It is important, therefore, to focus on quality and process rather than quantity.   A few interventions that are carefully linked, sequenced, and integrated with other activities will be more powerful than many program efforts that are discrete, isolated, and unrelated. Program Content As noted earlier, programs focusing on men's responsibility for preventing violence against women can address men's violence in general or focus on specific forms of violence, such as sexual assault and rape prevention, domestic violence prevention, dating violence prevention, stalking prevention, and sexual harassment prevention.   Other programs may address the issue of violence indirectly by teaching men relationship, parenting and fathering skills, how to manage aggression and anger, how men are socialized, and by providing positive re-socialization and bonding experiences for men.   There is some controversy in the field regarding whether these latter programs can be considered bona-fide violence prevention for men, with the answer depending on the content of the individual program and the degree to which links to men's violence are made explicit (for an excellent discussion of this issue go to www.endabuse.org/bpi/ in the Online Discussion Series).   Because they devote considerable attention to addressing socialization and cultural issues that underlie men's violence they certainly have a place in the larger task of redefining masculinity and male culture of which violence prevention is a part.   They may also be more appropriate with men who do not have a history of violence and when safety issues are not a concern.   Program Format Violence prevention programs that focus on changing individual men's behaviors can be offered as one-time only events, such as educational programs or workshops, or as multiple linked events over time.   These types of workshops have been traditional in the violence prevention field.   Recently, there have been attempts to also address the larger culture of violence and target the general population through the use of media in the form of social marketing campaigns that provide positive messages about men, social norms marketing campaigns that provide data about healthy anti-violence norms, and through activist events such as the White Ribbon Campaign and appropriate participation in Take Back the Night.   There is very little research on these larger efforts, although preliminary research suggests that social norms marketing campaigns can change relevant attitudes and in some cases behaviors (Berkowitz, 2003; Bruce, 2002; Hillenbrand-Gunn et. al, 2004; White, Williams & Cho, 2003).   It may be even more powerful to combine both types of interventions in a synergistic fashion so that men participating in individual workshops are also exposed to supportive media campaigns outside the workshop setting. Program Philosophy Violence prevention programs for men may differ in terms of their pedagogy, i.e., their philosophy regarding how to help men change.   Programs may focus on building empathy towards victims, the development of personal skills, learning to intervene in other men's behavior, re-socialization of male culture and behavior, or media efforts to change the larger environment.   While there has been debate about whether men's violence prevention efforts should be pro-feminist, it is this author's contention that violence prevention for men is pro-feminist by definition because it is about changing men in ways that support the feminist agenda of creating of a society in which women and men are treated equally and equitably (see Capraro, 1994 and Corcoran, 1992 for a discussion of the feminist underpinnings of men's anti-violence efforts).   These program philosophies are briefly summarized below. Fostering empathy for victims .   It is undeniable that men need to understand and be empathic to the experiences of victims and that development of such empathy may discourage men from harming women.   Presenting stories of victims in person, by video, or through interactive theater, can help create such understanding and empathy.   For victim stories to have an impact it is important that men's defensiveness first be reduced.   Victim empathy programs are useful when men are not sufficiently aware of the problem of men's violence.   However, they fall short of asking men to make changes in our own and other men's behavior and run the risk of appealing to a male-helper mentality.   In addition, they are not appropriate for coercive and/or opportunistic men with impaired empathy.   The literature on empathy induction programs has been reviewed by Berkowitz (2002a), Lonsway (1996) and Schewe (2002). Individual change .   Learning skills such as managing anger, understanding gender based privilege, relationship skills (including communication, partnership, and parenting skills), or how to ensure that intimate relationships are consenting can all help to reduce men's violence.   Research has established that deficiency in these skills is associated with violence and that teaching men these skills may decrease the likelihood of future violence when the acquisition and maintenance of these skills is encouraged in a supportive environment (Low, Monarch, Hartman, & Markman, 2002).   However, while focusing on personal skill development moves beyond empathy development by asking men to change behavior and take responsibility for actions and intentions in relation to others, it still does not address the larger cultural context that supports and maintains men's violent behaviors.   Bystander interventions .   Programs attempting to reduce bystander behavior teach men how to intervene in the behavior of other men (see for example, Berkowitz, 2002; Katz, 1995).   Men who are likely to commit violence are men who over-identify with traditional masculine values and roles and who are especially sensitive to what other men think.   The focus of bystander intervention programs is to provide the majority of men who are uncomfortable with these men's behavior with the permission and skills to confront them.   Bystander interventions move beyond empathy and individual change to make men responsible for changing the larger environment of how men relate to each other and to women.   This can change the peer culture that fosters and tolerates men's violence. Re-socialization experiences .   Socialization focused programs explore the cultural and societal expectations of men that influence how men are taught to think and act in relation to women.   A socialization-oriented discussion inevitably focuses on men's homophobia, heterosexism, and sexism. Social marketing and social norms marketing .   In recent years there has been an effort to augment and reinforce small group interventions through the use of media campaigns that portray men in positive, non-violent roles or through social norms marketing campaigns that provide data about the true norms for men's behavior (see Bruce, 2002; Hillenbrand-Gunn et al, 2004; Men Can Stop Rape, 2000; White, Williams, & Cho, 2003).   The social norms approach relies on the assumption that men commonly misperceive the attitudes and behaviors of other men that are relevant to violence.   For example, men think that other men are more sexually active than themselves, are more comfortable behaving in stereotypically masculine ways, are less uncomfortable with objectification of women and violence, are more homophobic and heterosexist, and are more likely to endorse rape myths (Berkowitz, 2003, 2004).   Because of the powerful influence that men have on each other, correcting these misperceptions can free men to act in ways that are healthier and more aligned with personal values.   In one study, for example, it was found that the strongest influence on whether men were willing to intervene to prevent violence against women was the perception of other men's willingness to intervene (Fabiano, Perkins, Berkowitz, Linkenbach, & Stark, 2004).   Thus, correcting misperceptions among men about violence-related attitudes is an emerging and important prevention strategy that can be implemented in media campaigns or in small group interventions.   All of these approaches are interdependent and overlap in practice.   Considering these four approaches is helpful in adapting a program to the needs and characteristics of a specific audience.   They can be thought of as occurring in a developmental sequence starting with creating an awareness of the problem of violence against women, to fostering personal change, and ending with a commitment to impact the behavior of other men, all within a context that is consistent with the goals and practices of feminist thinking. Summary Effective prevention programs for men must be developed that are consistent with the prevention literature - i.e., they must be comprehensive, intensive, and relevant.   These programs can focus on a variety of issues relevant to men's violence, including specific forms of violence and the larger cultural context that makes men's violence possible.   Such programs may attempt to foster empathy in men, change individual men's attitudes and behaviors, encourage men to intervene against other men's behavior, and provide men with positive re-socialization experiences.   Programs may also be developed utilizing social marketing and social norms marketing techniques to present images of men in new and different roles and by providing alternative perspectives on men's behavior. All of the programs share common assumptions and philosophies for working with men that were reviewed in Part One of this paper. Note: Portions of this review were adapted from Fostering Men's Responsibility for Preventing Sexual Assault and Working with Men to Prevent Sexual Assault , both written by the author in 2002. Author of this document: Alan David Berkowitz, Ph.D. Independent Consultant Founder and Editor of The Report on Social Norms Consultant: Dave Mathews, PsyD, LICSW Director of Therapy Domestic Abuse Project 204 W. Franklin Avenue Minneapolis, MN 55404 Citation: Berkowitz, A. (2004, October). Working with Men to Prevent Violence Against Women: Program Modalities and Formats (Part Two). Harrisburg, PA: VAWnet, a project of the National Resource Center on Domestic Violence/Pennsylvania Coalition Against Domestic Violence. Retrieved 10-4-09, from: http://www.vawnet.org References Berkowitz, A.D. (2001). Critical elements of sexual assault prevention and risk reduction programs. In C. Kilmartin (Ed.), Sexual assault in context: Teaching college men about gender (pp.75-96). Holmes Beach, FL: Learning Publications. Berkowitz, A.D. (2002a). Fostering men's responsibility for preventing sexual assault. In P. Schewe (Ed.), Preventing violence in relationships (pp.163-196). Washington, DC: American Psychological Association. Berkowitz, A.D. (2002b, Spring/Summer). Working with men to prevent sexual assault. Newsletter of the National Sexual Violence Resource Center, 2, 4-6. Berkowitz, A.D. (2003). Applications of social norms theory to other health and social justice issues. In H. Wesley Perkins, (Ed.), The social norms approach to prevention (pp.259-279). San Francisco, Jossey Bass. Berkowitz, A.D. (2004). The social norms approach: Theory, research and annotated bibliography . Retrieved July 28, 2004 from www.edc.org/hec/socialnorms/ Bruce, S. (2002). The "a man" campaign: Marketing social norms to men to prevent sexual assault. The Report on Social Norms: Working Paper #5. Little Falls, NJ: PaperClip Communications. Capraro, R.L. (1994). Disconnected lives: Men, masculinity and rape prevention. In A. Berkowitz (Ed.), Men and rape: Theory, research and prevention programs in higher education (pp.21-34). San Francisco, Jossey Bass. Carillo, R. & Tello, J. (1998). Family violence and men of color . New York: Springer. Corcoran, C. (1992). From victim control to social change: A feminist perspective on campus rape and prevention programs.   In J. Chrisler & D. Howard (Eds.), New directions in feminist psychology (pp.130-140). New York: Springer Verlag. Fabiano, P., Perkins, H.W., Berkowitz, A.B., Linkenbach, J. & Stark, C. (2004). Engaging men as social justice allies in ending violence against women: Evidence for a social norms approach. Journal of American College Health, 52 (3), 105-112. Hillenbrand-Gunn, T.L., Heppner, M.J., Mauch, P.A. & Park, H.J. (2004, August). Acquaintance rape and male high school students: Can a social norms intervention change attitudes and perceived norms? Paper presented at the annual convention of the American Psychological Association, Honolulu, Hawaii. Katz, J. (1995). Reconstructing masculinity in the locker room: The mentors in violence prevention project. Harvard Educational Review, 65 (2), 163-174. Lonsway, K.A. (1996). Preventing acquaintance rape through education: What do we know? Psychology of Women Quarterly, 20 , 229-265. Low, S.M., Monarch, N.D., Hartman, S. & Markman, H. (2002). Recent therapeutic advances in the prevention of domestic violence. In P. Schewe (Ed.), Preventing violence in relationships (pp.197-222). Washington, DC: American Psychological Association. Men Can Stop Rape (MCSR) (2000). Speaking with Men about sexism and sexual violence: Training packet. Washington, DC: Author. Pence, E. (1999). An introduction: Developing a coordinated community response. In M. Shepart & E. Pence (Eds.), Coordinating community responses: Lessons from Duluth and beyond (pp.3-23). Newbury Park, CA: Sage. Schewe, P.A. (2002). Guidelines for developing rape prevention and risk reduction interventions. In P. Schewe (Ed.), Preventing violence in relationships (pp.107-136). Washington, DC: American Psychological Association. White, J., Williams, L.V. & Cho, D. (2003). A social norms intervention to reduce coercive behaviors among deaf and hard-of-hearing college students. The Report on Social Norms: Working Paper #9 . Little Falls, NJ: PaperClip Communications. Update of the 'Battered Woman Syndrome' Critique Mary Ann Dutton With contributions from Sue Osthoff and Melissa Dichter Battering and the effects of battering are complex phenomena, which often are not well understood by the lay public. In addition to physical injury, individuals who have experienced battering often confront an array of psychological issues that differ in both type and intensity. The effects of domestic violence vary according to the social and cultural contexts of individuals' lives and include differences in the pattern, onset, duration, and severity of abuse. Importantly, this context is also determined by institutional and social responses to the abuser and to the survivor of abuse and many other factors characteristic of both persons in an abusive relationship: level of social support, economic and other tangible resources, critical life experiences (e.g., prior trauma, violence history, developmental history), and cultural and ethnic factors (Dutton, 1996; Dutton, Kaltman, Goodman, Weinfurt, & Vankos, 2005; Heise, 1998). Although individual women experience and respond to battering differently, a number of reactions are common among those who have been exposed to these traumatic events. “Battered woman syndrome” (BWS), a construct introduced in the 1970s by psychologist Lenore Walker, is sometimes used in an attempt to explain common experiences and behaviors of women who have been battered by their intimate partners (Walker, 1989; Walker, 2006) . However, through more than three decades of accumulated empirical research, we have come to recognize major limitations in both the original and revised conceptualizations of BWS, as well as with the term itself (Osthoff & Maguigan, 2005). The use of BWS to describe the experience of women who have been victimized by intimate partner violence or to explain their response to such violence and abuse is both misleading and potentially harmful. As currently defined, the construct of BWS has several important limitations: (1) BWS is often not relevant to the central issues before the court in a specific case, (2) BWS lacks a standard and validated definition, (3) BWS does not reflect current research findings necessary to adequately explain either the experience of individuals who have been battered or their behavior in response to battering, and (4) BWS can be unnecessarily stigmatizing (Biggers, 2005; Ferraro, 2003). This paper reviews the definition, evolution, and utilization of BWS in the courts, and offers a critique of its framework and its use. What is Battered Woman Syndrome? BWS is a term typically used to refer to women's experiences that result from being battered. It has evolved from a term used to describe a broad range the victim's (e.g., learned helplessness) and abuser's (e.g., cycle of violence) behaviors to a mental health disorder describing symptoms experienced by an individual following traumatic exposure (e.g., Posttraumatic Stress Disorder, PTSD). Learned Helplessness Initially, BWS was conceptualized as “learned helplessness” (Walker, 1977), a condition originally conceptualized by Seligman and his colleagues (Miller & Seligman, 1975) to describe the failure of dogs to escape a punitive environment, even when given the opportunity to do so. The theory was later used to explain depression in humans (Abramson, Seligman, & Teasdale, 1978). Walker (1977) applied the theory of learned helplessness to describe women's seeming lack of effort to leave or escape an abusive relationship or their failure or inability to take action to protect themselves and their children.   Seligman and colleagues (Peterson, Maier, & Seligman, 1993) have clearly refuted Walker's use of learned helplessness by stating that In sum, we think the passivity observed among victims/survivors of domestic violence is a middling example of learned helplessness. Passivity is present, but it may well be instrumental. Cognitions of helplessness are present, as is a history of uncontrollability. But there may also be a history of explicit reinforcement for passivity. Taken together, these results do not constitute the best possible support for concluding that these women show learned helplessness (p. 239). Seligman and colleagues further argue that passivity may be instrumental behavior that functions to minimize the risk of violence, instead of reflecting “learned helplessness” as it was originally conceptualized. Some women who have been battered may appear helpless or intentionally use “passive” behavior (e.g., giving in to demands) to stay safe. Indeed, research with low-income African-American women who have experienced domestic violence showed that, as violence toward women increased, they increased their use of both passive (placating) and active (resistance) strategies for dealing with the violence (Goodman, Dutton, Weinfurt, & Cook, 2003). Further, as Seligman suggested, women sometimes use strategies that may seem passive or tantamount to “doing nothing,” but these may actually be active efforts to reduce the risk of violence and abuse to themselves and their children. Indeed, the intended and actual function of a particular strategy is understood only in the context of the lives of the individual woman and her partner, as well as their relationship together. Cycle of violence Another early definition of BWS referred to the “cycle of violence” (Walker, 1984), a theory that describes the dynamics of the abuser's behavior, which is characterized in three stages: tension building, acute battering, and contrite loving. The theory suggests that the abuser keeps the survivor within his control largely by the contrite loving behaviors that follow even severe violence. There is little empirical evidence testing the cycle of violence theory. Walker's own early research showed that only some of the women interviewed in her study reported patterns of abuse consistent with this theory, with 65% of all cases reporting evidence of a tension-bulding phase and 58% of all cases reporting evidence of loving contrition afterward (Walker, 1984). Further, a recent study (Copel, 2006) of the patterns of abuse in a small sample of women with physical disabilities did not find a contrite loving phase in the aftermath of abuse. Posttraumatic stress disorder In an attempt to standardize criteria for BWS, Walker (1992) revised the definition to be synonymous with posttraumatic stress disorder (PTSD), a psychological condition which results from exposure to a traumatic event. Indeed, PTSD is described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000). Many single instances of domestic violence, and certainly the cumulative pattern of violence and abuse over time, easily meet the DMS-IV-TR criteria of a traumatic stressor. These criteria are (1) events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or other and (2) intense fear, helplessness, or horror. The symptoms that defined PTSD include (1) intrusive symptoms (images, thoughts, perceptions, nightmares; distress at exposure to cues that symbolize or remind one of the traumatic event; physiological reactivity to exposure to internal or external cues that resemble the traumatic event), (2) emotional numbing1 (feeling detached or estranged, inability to recall important aspects of the trauma) and behavioral avoidance (efforts to avoid thoughts, feelings, conversations associated with the trauma and activities, places and people that arouse recollections of the trauma), and (3) hyperarousal (difficulty sleeping, anger and irritability, difficulty concentrating, hypervigilance, exaggerated startle response) (American Psychiatric Association, 2000). The psychometric validity of PTSD symptoms has been recently validated with women exposed to intimate partner violence (Krause, Kaltman, Goodman, & Dutton, 2007). Walker again revised the definition of BWS in 2006 to include not only the three symptom clusters of PTSD (re-experiencing, numbing of responsiveness, hyperarousal), but also three additional criteria (disrupted interpersonal relationships, difficulties with body image/somatic concerns, and sexual and intimacy problems) (Walker, 2006). Many “associated features” (e.g., impaired ability to regulate emotion, dissociative symptoms, shame, feeling permanently damaged, hostility, social withdrawal, feeling constantly threatened, impaired relationships with others) often accompany PTSD, but these are not included in the criteria for its diagnosis. Walker has not provided a rationale for selecting a particular subset of these associated features and for including them as criteria for BWS. During the 1980s, BWS was included in educational programs and materials of many domestic violence advocates, in trainings for lawyers and judges and was used by some therapists and counselors to describe the experiences of women exposed to domestic violence. Having a scientific-sounding term like BWS to describe what they learned from talking and working with women who had experienced domestic violence proved useful in some cases; it increased credibility with other professionals and the general public. However, as the field developed, more and more practitioners grew to understand the problems and limitations of using BWS; most stopped using the term. During the past 15 years, numerous articles and books have been published discussing the limitation of BWS (Ferraro, 2003; Ferraro, 2006; McMahon, 1999; Schuller, Wells, Rzepa, & Klippenstine, 2004; Stark, 2007; USDOJ/DHHS, 1996). Instead, today many practitioners use the term “battering and its effects” to describe the experiences of women exposed to domestic violence (Osthoff & Maguigan, 2005). Even so, it is important to note that some experts and attorneys continue to utilize the term BWS in their work.   Use of BWS in Expert Testimony Expert testimony about battering and its effects has been introduced in a wide range of criminal and civil cases. Most typically, it has been introduced by the defense in cases involving women who are criminally charged, especially women who have killed their abusers. It can also be offered by the prosecution in criminal cases, usually to explain why the survivor of a crime has recanted or is unwilling to participate in the prosecution, or to explain other behaviors that might be difficult for jurors to understand without the aid of expert testimony (e.g., why don't the survivors leave, why would a survivor return to an abuser, why did the survivor act emotionally unaffected right after a shooting). Expert testimony about battering and its effects has also been introduced in civil matters, such as child custody cases, marital dissolution, tort, or personal injury cases. Here we will focus more heavily on the use of the testimony in criminal cases, and more specifically in self-defense cases, although many of the issues described here are also applicable to other uses of expert testimony. It is in the legal (rather than clinical) arena that BWS continues to be most firmly embedded and to receive the most attention. Indeed, the term BWS appears in some state statutes, as well as in numerous legal decisions. Even today, it is not uncommon to hear about cases that involve expert testimony on BWS. Notwithstanding widespread misconception, BWS is not a legal defense. Regrettably, even to this day, many myths persist about a specialized legal defense using the BWS. Osthoff and Maguigan (2005) outline five basic misconceptions related to the legal defense of women exposed to domestic violence. The most central misconception is that defendants who have been battered invoke a separate “battered syndrome defense.” There is no special “battered women's defense” or “battered woman syndrome defense” (Maguigin, 1991; USDOJ/DHHS, 1996). Other important misconceptions are that expert testimony is only about BWS and that it is based on an analysis of the victimization dynamic only, excluding information about women's strengths, including responsibility (e.g., taking care of her children, providing economic resources to her family), agency (e.g., making decisions intended to protect herself and her children from violence and abuse), and capacity (e.g., competence to act independently and endurance to continue functioning in the face of great adversity).     Both expert and lay testimony about battering and the effects of battering may be useful in support of (but not to replace) already existing legal defenses, such as self-defense or duress when the defendant in a criminal case is a women who has experienced domestic violence. Also, it may be offered to explain the defendant's behavior to support a different criminal defense or defense theory other than self-defense or duress and/or to negate the specific intent element of a crime.   In criminal cases involving a woman who has experienced domestic violence as the defendant, it is necessary for jurors to understand why the defendant did what she did. The context of her behaviors – including her motivation – is essential for determining the ultimate issues in a criminal case. For example, a homicide can be ruled as murder if judged to be premeditated “cold-blooded” intent to kill, or it can be ruled as justifiable if understood as an act of self-defense from a “reasonable” perception of danger. When the defendant is a woman who has been battered, what she did (and in some cases, did not do) is not always understandable to the lay individuals on the jury. Judges and jurors can hold myths and misconceptions, which may result from their limited experiences with women who have been battered, and bring these misunderstandings and biases to the bench or jury box. Without information to better understand the defendant's experiences and behaviors, judges and jurors often inaccurately evaluate and unfairly judge the defendant. For example, they may not understand why the defendant did not “simply” leave the batterer, assuming that leaving would have made the woman safe. As a result, they may blame the woman for the abuse she experiences. They may believe that unless the defendant had previously reported the abuse, she is not to be believed when she later asserts self-defense against an abusive partner. It is essential that judges and jurors have the information necessary to fairly understand a defendant's situation, especially when jurors are asked to put themselves “in the defendant's shoes.”   Thus, expert testimony can be useful to aid the factfinder in determining the “ultimate issue” (e.g., in a self-defense case, reasonable perception of immediate danger), as well as to educate the factfinder about common myths and misconceptions (Maguigin, 1991) . Expert testimony may cover a wide range of topics, such as domestic violence and abuse, characteristics of abusers, the emotional and physical effects of violence and abuse on women and children exposed to domestic violence, women's efforts to protection herself and her children, women's use of strategies to cope with domestic violence, including the use and responsiveness of community resources, the impact of domestic violence on economic stability, employment, and social and family relationships and the influence of contextual factors (e.g., race and ethnicity, economic status, prior trauma history, alcohol and substance abuse, physical and mental health status) on battering and the effects of battering.   What is Wrong with Battered Woman Syndrome? Even though expert witness testimony can be useful in cases involving domestic violence, there are serious limitations of using BWS as the framework for this work. Where expert testimony is used to explain an individual's state of mind or behavior, to support a particular defense, or to bolster credibility (when allowed) in situations that might otherwise seem unreasonable or unlikely (Parish, 1996) , a packaged “syndrome” can be convenient and have the perceived legitimacy of a “diagnosis” (Schuller & Hastings, 1996). A number of factors, however, make this package particularly problematic. The most fundamental of these concerns is the lack of relevance of BWS to the issues before the court. A second concern is the lack of a standard and validated definition of BWS with which to guide experts' use in evaluation and testimony. Third, BWS does not adequately incorporate the vast scientific literature on victims' response to battering. Finally, BWS suggests a pathology that can stigmatize the defendant unnecessarily and inaccurately.   BWS may not be relevant to the issues before the criminal court. An initial limitation of BWS testimony is that it may not be relevant to the specific issues before the court in a particular case; that is, PTSD (whether referred to as BWS or not) simply may not be relevant for those issues which require explanation by the expert witness. For example, BWS may not be helpful for explaining why a woman returns to an abuser after separating or fails to call police. She may be reluctant to tell others about the abuse. Expert witness testimony may be needed to challenge mischaracterizations when a woman is well-educated, has access to economic resources, or has specialized training (e.g., police officer) since a judge or jury often does not understand how such a woman could not simply leave or protect herself against an abusive partner. BWS is not particularly relevant for these issues. A woman who appears unemotional right after or right before shooting her abusive husband may be thought merely to have killed in “cold blood.” PTSD may be relevant here, but dissociation as a part of acute stress disorder may be even more accurate. Certain experiences that an abused woman may have had (e.g., substance abuse history, prostitution, criminal history) can easily lend themselves to victim blaming. Expert witness testimony may be required to understand how these experiences do not necessarily negate the reality that the woman may have been abused by her partner, or that she perceived her partner's behavior as an imminent threat to her safety. These particular experiences may make it even more difficult for a woman who is being abused to seek help and effectively protect herself and her children from abuse. Typically, BWS is not adequate or perhaps even relevant to these issues. According to Federal Rule 702, "If scientific, technical, or other specialized knowledge will assist the trier of fact to understand the evidence or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or education, may testify thereto in the form of an opinion or otherwise" (Federal Rule of Evidence, 2009). There is a great deal of scientific literature that can be brought to bear and is potentially helpful to understand the evidence and to determine facts in issue in domestic violence cases. However, BWS is simply insufficient to this task. First and foremost, an expert witness needs to know the relevant questions for which expert testimony is needed. Too often an attorney will begin with one question: “Does she have BWS?” without considering the particular relevance of this question to the defense theory or considering how the defendant's particular abusive history is specifically relevant to her conduct. The goal of the expert testimony in most cases is not to “prove” that the defendant has been battered. Rather an expert can help the jury understand better the defendant's experience of abuse and why those experiences are legally relevant. For example, in self-defense cases, perhaps the most relevant question is, "What factors would inform the court to better evaluate the defendant's assertion that she was in immediate danger?" When the expert focuses his or her evaluation on this question, the result is an analysis of those factors that support or fail to support the reasonableness of the defendant's perception of immediate danger, given the circumstances. Since the expert cannot testify to the ultimate issue, the expert offers to the court an analysis that allows the trier of fact to make a more informed decision about these “ultimate” issues. BWS is neither necessary nor sufficient to explain the defendants' perception of immediate danger. Relying on BWS as the primary explanation for the defendant's perception of danger offers the untenable formulation that only when the defendant has a clinical diagnosis of PTSD is her perception of danger reasonable. BWS is simply not a sufficient explanation for this central question or most other questions typically posed to the expert witness in criminal cases involving a woman who has experienced domestic violence BWS lacks a standard definition and evidence of scientific validity. BWS – even as currently conceptualized – lacks both a standard definition and evidence of scientific validity for many of the purposes for which it is used. As stated, BWS is not recognized in the DSM-IV-TR. Although the International Classification of Diseases, 10th Version (ICD-10; World Health Organization, 1993), classifies “battered spouse syndrome” and “effects of abuse of an adult” as maltreatment syndromes, these do little to clarify the definition for use in legal matters. Although numerous articles have been written about BWS, few include validation through empirical research. The term BWS does appear in several state laws, but its definition is not consistent from state to state when a definition is actually included in the language of the statute, which often it is not. If it is argued that BWS is really just PTSD, then BWS is entirely redundant and there is no need for a separate term. Clear and well-validated criteria for a PTSD diagnosis exist. Expert testimony relying primarily on PTSD can – and is – used by expert witnesses in court. However, it is only appropriate to do so when PTSD is relevant for explaining a particular issue before the court that might not otherwise be well understood by the jury or judge. PTSD might well explain important issues before the court in some cases. An example is when a woman's perception of danger is explained by an intrusive recollection or subjective experience of “reliving” prior domestic violence that may be “triggered” by events leading to the criminal act (e.g., shooting). In this example, the focus is on the woman's internal psychological state (e.g., PTSD), not on external events to explain the perception of threat posed by the abuser's behavior. While this explanation “fits” some battered women who might – due to PTSD – experience objectively nonthreatening events as threatening and might respond in self-defense, it fails to account for many women's accurate understanding of unique danger cues learned over repeated incidents of violence and abuse from their abusive partners. Indeed, there is a large scientific literature pertaining to PTSD, including empirical research, theoretical and conceptual articles, and clinical case studies. And, a significant portion of this research includes victims of domestic violence and sexual assault, as well as other types of traumatic events, such as child abuse, vehicle accidents, terrorism, and combat. At this point in time, the scientific community does not distinguish PTSD arising from one type of trauma vs. another. When the diagnostic criteria are met, a PTSD diagnosis is appropriate regardless of trauma type. However, clear scientific evidence for PTSD does not translate to support of the construct of BWS. There is no “type” of PTSD called BWS.   The inclusion of associated features in Walker's 2006 revised definition of BWS further contributes to the lack of standardization in its definition. The reliability of several of the measurement scales used in Walker's study (2006) to “operationalize” BWS using these additional indicators of BWS is unacceptably low. Further, no threshold level of these additional criteria for defining BWS was described. For example, how much or what kind of body image distortion is required to meet criterion for BWS? Does sexual dissatisfaction refer to an abusive partner or someone else and how much dissatisfaction is required to be considered BWS? Again, how much loss of the perception of power and control is necessary? Regrettably, Walker's newer definition has clouded the criteria for assessing BWS even more than had previously been the case. Perhaps more importantly, these issues really have little relevance for many issues raised in criminal cases? Without standard and validated criteria, we do not have a way to determine with reliability who meets criteria for BWS and who does not. This is a problem in the legal context because, without a scientifically accepted definition or standard criteria, the use of BWS can fail to meet basic standards of scientific reliability and, therefore, may be inadmissible as expert testimony in court under the scientific reliability prong according to Daubert v. Merrl Dow Pharmaceuticals (1993). In sum, because it is not clear what is meant when we say BWS and because we do not have a clear way of measuring the condition, BWS is not even a good shorthand term for explaining the experience of women who have been abused by their intimate partners. Thus, the lack of a clear definition of BWS makes it difficult for jurors and judges, attorneys, parties to a legal case and the lay public, to understand even what is being referred to when the term BWS is used. BWS does not adequately incorporate current research. The state of knowledge concerning battering and its effects has increased dramatically in the past three decades since BWS was first introduced. Simply, scientific knowledge continues to expand on an ongoing basis as new research is completed. A qualified expert witness is compelled to rely on the most rigorous available scientific evidence that is pertinent to an evaluation of a defendant and providing expert testimony. When an expert witness is called to testify in a legal matter involving battering and its effects, he or she is required to have command of the current scientific literature as the foundation for sound theoretically- and empirically-based testimony. It is clear from the current scientific literature what advocates have known, which is that no single profile adequately characterizes women's experiences following domestic violence. BWS is often used to describe victims as if they all experience similar effects from having been exposed to battering and all respond in the same way. For example, we know that patterns of violence and abuse vary across women, as does their desire to remain in relationships, the extent to which they stay or leave (Bell, Goodman, & Dutton, 2007) , and the extent of traumatic effects (Dutton et al., 2005) . BWS is often used as if it were a standard against which to determine whether a particular woman is justified in her actions against an abusive partner, is credible as a woman claiming to have experienced domestic violence, or deserves consideration in some other way. While we know that there is a range of common reactions to being battered by an intimate partner (Dutton, Hohnecker, Halle, & Burghardt, 1994) , how an individual woman experiences or reacts to being battered will vary depending on her psychological, social, cognitive and practical circumstances. Given this reality, it is not appropriate to describe “the profile of a battered woman” or to describe the effects of battering as a “syndrome.” The expert witness must rely on the continually expanding body of existing scientific literature to develop a formulation in each case about factors that address pertinent questions posed to the expert. This body of scientific knowledge, which provides relevant information for the issues before the court, is extensive. A few of these research areas include primary stress appraisal (“How do victims evaluate the seriousness of actual and threatened violence and abuse?”), secondary stress appraisal (“What options do abused victims perceive that they have to deal with violence and abuse?”), coping (“What do victims actually do to deal with violence and abuse?”, “Why don't victims leave or do other things that some others might expect?”), traumatic stress reactions (“What are the traumatic and related mental health effects of being exposed to violence and abuse?”), and social and cultural context (“How does having children, poverty, gender, racism, immigration status, heterosexism, and other social and cultural factors influence a victim's experience of violence?” “How do these factors influence the way in which she responds to it?”). Notably, there is very little empirical research on BWS per se. A full discussion of alternatives to BWS as a framework for expert testimony in cases involving battering is beyond the scope of this paper. Briefly, these include expert testimony referred to as “social agency” (Schuller et al., 2004; Schuller & Hastings, 1996) or social framework (Monahan & Walker, 1988) testimony, both of which are available generally to criminal defendants and are not specific to the defense of victims of domestic violence. Another option is simply referring to the testimony as about “battering and its effects” (Osthoff & Maguigan, 2005; USDOJ/DHHS, 1996). These three approaches all refer to the idea that the issues presented to the expert can be explained in terms of the context in which victims experience violence and abuse – relying on the available scientific literature and the expert's experience to inform that testimony.   BWS can be stigmatizing. For whom is BWS intended to explain experience and behavior? The answer is not clear. BWS is sometimes used as if to describe the experiences of all women who have experienced domestic violence. At other times, it is used to describe a stereotypic image of the so-called “good” or “sympathetic battered woman.” The “image” of a woman who has experienced domestic violence is often clouded by stereotypes based on race, culture, ethnicity, social and economic class, and sexual orientation.   BWS often evokes the image of a woman who ends up “snapping” and killing her abusive partner. BWS often creates a stigmatizing image of pathology, which may affect the decision-making of judge, jury, clinician, and/or researcher (Schuller et al., 2004). Interestingly, some research using simulated jurors found that testimony utilizing BWS and PTSD in combination was associated with jurors' opinions focusing on the women's deficits, a pathological view of the hypothetical defendant, even more than BWS alone (Terrance & Matheson, 2003) . Although BWS is intended to explain the experience of women who have been abused, the use of “syndrome” language defined essentially as a mental disorder (PTSD) helps to create an image of pathology. Ironically, a woman with PTSD may also reasonably perceive immediate danger, but not because of PTSD. Nevertheless, the image of PTSD or BWS runs counter to the self-defense argument that the defendant's perception of immediate danger was reasonable for someone in her circumstances and therefore that her actions were justifiable under the law. It is difficult to argue that a defendant who is viewed as “flawed,” “damaged,” “disordered” or “abnormal” by virtue of a mental health diagnosis (PTSD) should be justified in her actions based on the reasonableness of her perceptions. Her perceptions – and even her actions – may be understandable, given her history of domestic violence and its impact on her (e.g., PTSD). However, this argument is likely to be insufficient for a straightforward self-defense claim. Expert testimony to explain a victim's experience and behavior must also rely on information about non-psychological effects of battering, including disruption of a woman's economic stability and employment, impairment in physical health, and alterations in her view of the world and others in such a way as to influence her trust of others and sense of safety in day-to-day life. Women can feel trapped in an abusive relationship because of the very real threat of further violence, lack of economic resources, and lack of institutional and social support (Anderson et al., 2003; Fleury, Sullivan, & Bybee, 2000) . In most cases, a woman's behavior is best characterized as logical within the context of her abuser's behavior and functional in its attempt to stop the violence and abuse, not the product of a mental health problem. Although emotional dependence and feelings of hopelessness may keep a woman in a relationship with an abusive partner (Short, McMahon, Chervin, Lezin, Sloop, & Dawkins, 2000), these emotions are not defined as a mental disorder. Even when mental health problems, such as PTSD and depression, result from battering, and influence a woman's decisions or her behavior, they are usually only a part of it. Empirical evidence has found that predictions of risk of future assault by women who have experienced domestic violence are often correct (Bell, Cattaneo, Goodman, & Dutton, 2008; Cattaneo, Bell, Goodman, & Dutton, 2007; Heckert & Gondolf, 2004; Weisz, Tolman, & Saunders, 2000). If a women's behavior is not understood in the full context of their lives, important decisions in a legal case can be incorrectly influenced by stereotypes or assumptions about how or why women who are battered behave the way that they do. In sum, the concept of BWS does a poor job of describing for the court the range of experiences or behaviors of women exposed to domestic violence. Thus, in the courtroom, the use of BWS by those with scientific knowledge and specialized experience with domestic violence fails to serve those who demand, and deserve, the very best: jurors and judges and, ultimately, women who have endured domestic violence. Conclusion             The conceptualization of BWS helped the field focus on the fact that battering has adverse effects on those who have been exposed to it. Over three decades later and an accumulation of a wealth of scientific knowledge, BWS is now recognized as a flawed model (Rothenberg, 2002, 2003), even as a shorthand reference. Its use persists, in part, because it conveniently packages in a single phrase a far more complex issue. Indeed, we need to understand the unique experiences of each defendant informed by the large and continually growing body of scientific literature that is pertinent for understanding an individual's experience and reaction to having been exposed to domestic violence. This information can be invaluable in support of expert testimony for explaining the state of mind and behavior of a woman who has experienced domestic violence and who has been charged with criminal conduct that was influenced by her history of violence and abuse. Author of this document: Mary Ann Dutton, Ph.D. Professor and Associate Director Center for Trauma and the Community Department of Psychiatry Georgetown University Medical Center Consultants: Sue Osthoff and Melissa Dichter National Clearinghouse for the Defense of Battered Women Philadelphia, PA Endnotes 1 Emotional numbing and behavioral avoidance symptoms are combined in a single symptom cluster in the DSM-IV-TR diagnostic criteria. 2 In some states, this situation may give rise to an “imperfect self-defense,” but this option varies across jurisdictions.   Citation: Dutton, M. A. (2009, August). Update of the "Battered Woman Syndrome" Critique. Harrisburg, PA: VAWnet, a project of the National Resource Center on Domestic Violence/Pennsylvania Coalition Against Domestic Violence. Retrieved month/day/year, from: http://www.vawnet.org   References Abramson, L. Y., Seligman, M. E., & Teasdale, J. D. (1978). Learned helplessness in humans: critique and reformulation. Journal of Abnormal Psychology, 87 (1), 49-74. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author. Anderson, M. A., Gillig, P. M., Sitaker, M., McCloskey, K., Malloy, K., & Grigsby, N. (2003). "Why Doesn't She Just Leave?": A Descriptive Study of Victim Reported Impediments to Her Safety. Journal of Family Violence, 18 (3), 151-155. Bell, M. E., Cattaneo, L. B., Goodman, L. A., & Dutton, M. A. (2008). Assessing the risk of future psychological abuse: Predicting the accuracy of battered women's predictions. Journal of Family Violence, 23 (2), 69-80. Bell, M. E., Goodman, L. A., & Dutton, M. A. (2007). The dynamics of staying and leaving: Implications for battered women's emotional well-being and experiences of violence at the end of a year. Journal of Family Violence, 22 (6), 413-428. Biggers, J. R. (2005). The Utility of Diagnostic Language as Expert Witness Testimony: Should Syndrome Terminology Be Used in Battering Cases? Journal of Forensic Psychology Practice, 5 (1), 43-61. Cattaneo, L. B., Bell, M. E., Goodman, L. A., & Dutton, M. A. (2007). Intimate partner violence victims' accuracy in assessing their risk of re-abuse. Journal of Family Violence, 22 (6), 429-440. Copel, L. C. (2006). Partner abuse in physically disabled women: a proposed model for understanding intimate partner violence. Perspectives Psychiatric Care, 42 (2), 114-129. Dutton, M. A., Hohnecker, L. C.,   Halle, P. M., & Burghardt, K. J.(1994) . Traumatic Responses Among Battered Women Who Kill. Journal of Traumatic Stress, 7 (4), 549-564. Dutton, M. A. (1996). Battered women's strategic response to violence: The role of context. In J. L. Edleson & Z. Eisikovits (Eds.), Future interventions with battered women and their families. (pp. 105-124). Thousand Oaks, CA: Sage. Dutton, M. A., Kaltman, S., Goodman, L. A., Weinfurt, K., & Vankos, N. (2005). Patterns of intimate partner violence: Correlates and outcomes. Violence and Victims, 20 (5), 483-497. "Federal Rules of Evidence." Legal Information Institute. 2009. Retrieved July 27, 2009 from Cornell Law School: http://www.law.cornell.edu/rules/fre/ Ferraro, K. J. (2003). The words change, but the melody lingers: The persistence of the battered woman syndrome in criminal cases involving battered women. Violence Against Women, 9 (1), 110-129. Ferraro, K. J. (2006). Neither angels nor demons. Lebanon, NH: Northeastern University Press. Fleury, R. E., Sullivan, C. M., & Bybee, D. I. (2000). When ending the relationship does not end the violence: Women's experiences of violence by former partners. Violence Against Women, 6 (12), 1363-1383. Goodman, L., Dutton, M. A., Weinfurt, K., & Cook, S. (2003). The Intimate Partner Violence Strategies Index: Development and application. Violence Against Women, 9 (2), 163-186. Heckert, D. A., & Gondolf, E. W. (2004). Battered women's perceptions of risk versus risk factors and instruments in predicting repeat reassault. Journal of Interpersonal Violence, 19 (7), 778-800. Heise, L. L. (1998). Violence against women: An integrated, ecological framework. Violence Against Women, 4 (3), 262-290. Krause, E. D., Kaltman, S., Goodman, L. A., & Dutton, M. A. (2007). Longitudinal factor structure of posttraumatic stress symptoms related to intimate partner violence. Psychological Assessment, 19 (2), 165-175. Maguigin, H. (1991). Battered women and self-defense: Myths and misconceptions in current reform proposals. Univeristy of Pennsylvania Law Review, 140 (2), 379-486. McMahon, M. (1999). Battered women and bad science: The limited validity and utility of battered woman syndrome. Psychiatry, Psychology and Law, 6 (1), 23-49. Miller, W. R., & Seligman, M. E. (1975). Depression and learned helplessness in man. Journal of Abnormal Psychology, 84 (3), 228-238. Monahan, J., & Walker, L. (1988). Social science research in law: A new paradigm. American Psychologist, 43 (6), 465-472. Osthoff, S., & Maguigan, H. (2005). Explaining without pathologizing: Testimony on battering and its effects. In D. R. Loseke, R. J. Gelles & M. M. Cavanaugh (Eds.), Current Controversies on Family Violence. Thousand Oaks: Sage Publications. Parish, J. (1996). Trend analysis: Expert testimony on battering and its effects in criminal cases. In The validity and use of evidence concerning battering and its effects in criminal trials: Report responding to section 40507 of the Violence Against Women Act. (NCJRS #160972). U.S. Departments of Justice and Health and Human Services. Retreived June, 2008 from http://www.ncjrs.org/pdffiles/ batter.pdf for Adobe or http://www.ncjrs.org/ txtfiles/batter.txt for text. Peterson, C., Maier, S. F., & Seligman, M. E. P. (1993). Learned helplessness: A theory for the age of personal control. New York: Oxford University Press. Rothenberg, B. (2002). The Success of the Battered Woman Syndrome: An Analysis of How Cultural Arguments Succeed. Sociological Forum, 17 (1), 81-103. Rothenberg, B. (2003). "We Don't Have Time For Social Change": Cultural Compromise and the Battered Woman Syndrome. Gender & Society, 17 (5), 771-787. Schuller, R., Wells, E., Rzepa, S., & Klippenstine, M. A. (2004). Rethinking Battered Woman Syndrome Evidence: The Impact of Alternative Forms of Expert Testimony on Mock Jurors' Decisions. Canadian Journal of Behavioural Science, 36 (2), 127-136. Schuller, R. A., & Hastings, P. A. (1996). Trials of battered women who kill: The impact of alternative forms of expert evidence. Law and Human Behavior, 20 (2), 167-187. Short, L. M., McMahon, P. M., Chervin, D. D., Shelly, G. A., Lezin, N., Sloop, K. S., et al. (2000). Survivors' Identification of Protective Factors and Early Warning Signs for Intimate Partner Violence. Violence Against Women, 6 (3), 272-285. Stark, E. (2007). Coercive Control. New York: Oxford University Press. Terrance, C., & Matheson, K. (2003). Undermining reasonableness: Expert testimony in a case involving a battered woman who kills. Psychology of Women Quarterly, 27 (1), 37-45. USDOJ/DHHS. (1996). The Validity and Use of Evidence Concerning Battering and Its Effects in Criminal Trials (No. NCJ 160972). Washington, D.C.: USDOJ, OJP, NIJ and DHHS, NIMH. Walker, L. E. (1977). Battered women and learned helplessness. Victimology, 2 (3-4), 525-534. Walker, L. (1984). The battered women syndome. New York: Springer. Walker, L. E. (1989). Psychology and violence against women. American Psychologist, 44 (4), 695-702. Walker, L. E. (1992). Battered women syndrome and self-defense. Symposium on Woman and the Law. Notre Dame Journal of Law, Ethics and Public Policy, 6 (2), 321-334. Walker, L. E. (2006). Battered woman syndrome: empirical findings. Annals of the New York Academy of Sciences, 1087, 142-157. Health Needs of Human Trafficking Victims July 2009 By: Erin Williamson, Nicole M. Dutch, and Heather J. Clawson Caliber, an ICF International Company Introduction On September 22 - 23, 2008, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) within the U.S. Department of Health and Human Services (HHS) sponsored a national symposium focused on the health needs of human trafficking victims. This symposium developed from an exploratory study, funded by ASPE, examining how HHS programs are addressing the needs of victims of human trafficking. This symposium brought together health care workers and members of the anti-human trafficking community to discuss trafficking victims’ health needs, how best to identify victims in health care settings, and ways that the health care system can provide improved and effective health care services to this population. More than 150 experts and professionals from a variety of fields attended the symposium. Attendees included directors of national medical  associations; program directors of hospitals located in communities highly affected by human trafficking; medical personnel working in clinics and organizations serving victims of human trafficking; executive directors of anti-trafficking organizations; and government officials from HHS, U.S. Department of Justice, U.S. Department of Labor, U.S. Department of State, U.S. Department of Education, U.S. Agency for International Development, and U.S. Congress. The symposium was organized in five major panel sessions, each of which ended with a discussion among attendees and panelists. Session 1, Introduction to Trafficking as a Health Issue, provided an overview of the issue including the role of various government agencies working to combat human trafficking, major cases prosecuted by the Department of Justice, certification of international victims by the Office of Refugee Resettlement within HHS, and the major health consequences of human trafficking. Session 2, Encountering Victims: Identification, Disclosure, and Other Issues, took a closer look at victims of human trafficking, challenges in identifying victims, key indicators to improve identification, how victims present themselves to health care settings, and how the Health Insurance Portability and Accountability Act might affect services to this population.  Sessions 3 and 4 focused on Health Service Provision to Victims, examined the physical, emotional, and mental health issues affecting this population, public health concerns resulting from human trafficking, medical services currently available, and additional resources needed to improve service delivery. In Session 5, Lessons Learned and Promising Practices, agencies successfully treating the physical and mental health needs of human trafficking victims described their programs and promising practices. This brief presents an overview of the major topic areas discussed during the National Symposium on the Health Needs of Human Trafficking Victims. The brief focuses primarily on the post-session discussions and suggestions to improve the delivery of health services to victims. Understanding the Definition of Human Trafficking and its Relationship to Other Populations The Trafficking Victims Protection Act of 2000 (TVPA) defines trafficking as the use of force, fraud, or coercion to compel labor and/or commercial sexual activity. Under this definition, human trafficking can present itself in multiple ways and numerous settings. While the TVPA legally defines human trafficking, symposium participants and anti-trafficking experts pointed out that this comprehensive definition is not often used in the public arena, and sometimes it is not even employed by anti-trafficking service providers and advocates, who might view human trafficking as confined to foreign-born women subjected to sex trafficking. These discussants cited the media and other public outlets as common sources providing a restricted view of human trafficking that applies only to female victims of sex trafficking. This narrow focus disregards the significant number of male and transgender victims, as well as the millions of victims of labor trafficking who may not have experienced sexual coercion as well. It also does not adequately recognize those U.S. citizens or legal permanent residents subjected to sex or labor trafficking who never cross any national boundaries (i.e., domestic victims). The relevant criteria establishing whether an individual is a trafficking victim is the presence of force, fraud, or coercion, not movement across geographical space or membership in any nationality group. In addition, anti-trafficking representatives pointed out that victims are sometimes defined narrowly as coming from the same background or sub-population. For example, reports on child sexual exploitation often assert that a significant number of minor, domestic female victims of commercial sexual exploitation are runaways. While this may be true for some domestic victims, assuming this is the case for all such female minor victims of sex trafficking may result in practitioners maintaining false assumptions and/or obtaining incomplete and inaccurate histories; this can result in unanticipated and potentially hazardous treatment strategies and outcomes. For example, if a physician working with a juvenile patient assumes he or she is a runaway, the physician may infer that something at the patient’s home prompted him or her to run away. This assumption could hinder family reunification for victims who are not runaways, or for whom reunification may be preferable. Symposium attendees representing multiple constituencies emphasized the importance of understanding that victims of trafficking can come from a variety of backgrounds and experiences and exhibit a wide range of characteristics. Symposium attendees concluded that discussions on human trafficking must take place at the practitioner and policy levels and incorporate a comprehensive definition of human trafficking in order to address the health issues facing this population and ensure proper care for all victims. However, within this broad definition are several discrete categories of victims who often may need different types of services and support. Sub-Populations of Human Trafficking that Require Specialized Attention Domestic victims of human trafficking were a sub-population discussed frequently throughout the symposium. While the majority of human trafficking victims in the United States are U.S. citizens, law enforcement, medical practitioners, and social service providers all pointed out that the resources for domestic victims are not comparable to those available for international victims. They observed that shelter is one of the most inadequate resources for domestic victims. While advocates for victims of domestic violence have effectively demonstrated the need for and benefits of shelters, social service practitioners note these shelters typically do not have the necessary personnel or resources to support victims of human trafficking, especially victims of labor trafficking. In some cases, female victims of trafficking refer to pimps as boyfriends, thus confusing whether cases involve domestic violence or trafficking. Additionally, shelters tend to be for females and, therefore, unavailable for male and transgender victims of human trafficking. Law enforcement and community organizations report having a difficult time locating adequate short- and long-term housing for domestic victims who escape their trafficking situations. As a result, many domestic minor victims are housed in juvenile detention centers, which often do not recognize or treat these youth as victims of a crime, but rather as perpetrators. A number of attendees identified the need for additional resources to establish specialized short- and long-term housing options for domestic victims, particularly minors. Social service providers also noted that accessing public benefits can be difficult for domestic victims of human trafficking. They report that while programs such as food stamps and Temporary Assistance for Needy Families (TANF) exist, they have eligibility requirements that may limit participation by domestic victims. For example, the Food Stamp program (now called the Supplemental Nutrition Assistance Program, or SNAP) generally requires applicants to have proof of address, a birth certificate, and a Social Security card, which most domestic victims do not have at the time they escape their trafficking situations. While victims can apply for various forms of identification, this process can be cumbersome and time-consuming, leaving victims at high risk for re-victimization and hindering attempts to receive public assistance. Additionally, prior arrests for solicitation or other offenses often result in ineligibility for food stamps and other programs. TANF requires individuals to be at least 18 years of age and have at least one child. As a result, social service providers report that minors with children and adults without children are generally ineligible for this program. Adults and children with special needs are also likely to require particular attention and services. Social service providers and researchers report that individuals with special needs are disproportionately targeted by traffickers. They added that these victims may be more vulnerable due to mental impairments as well as their need for financial resources to pay for medical care. Very little is known about how best to treat and work with this sub-population in the short-term as well as what resources are needed for their long-term care. Victims of labor trafficking may also require special attention. For example, they may suffer permanent and/or chronic medical conditions requiring intensive and lifelong treatment. For children, these medical conditions can severely affect their physical development. One example of this is children exposed to chemicals harming their respiratory system and hindering proper lung development. In addition, victims of labor trafficking may also have experienced sexual assault during their trafficking experience, putting them at risk for an increased number of associated health and mental heath issues. Since little research exists regarding labor trafficking, including the number of victims and their needs, as well as the health consequences of labor trafficking in the United States, more work is needed to ensure the health care needs of this sub-population are properly identified and met. Attendees also pointed out that children of adult victims require specialized attention, especially children who are at heightened risk for trafficking as a result of their mothers being in prostitution. Social service providers report that more resources are needed to effectively identify and prevent these children from becoming victims themselves. Gay, lesbian, and transgender youth are also at elevated risk for trafficking according to victim service providers. When these children escape their trafficking situations, they often need specialized support and services to help them overcome significant identity issues that can result from their trafficking experiences. For example, social service providers report that domestic, female victims of trafficking often initially identify themselves as being lesbian then later identify as straight or bi-sexual. There is little known regarding the cause of this phenomenon or whether these identity issues existed prior to their trafficking experience; however, providers note that this issue of identity is one that many domestic female victims struggle with as part of their recovery. Children and adults can also experience re-victimization if their images have been posted online. Medical professionals serving victims of human trafficking cited online images as a major factor in computer aversion, which can significantly affect completing school or attaining gainful employment. Additionally, representatives of anti-trafficking organizations report that more attention is required for children who are trafficked into the United States for the purposes of adoption, as well as U.S. children trafficked abroad. Physical and Mental Health Professionals’ Roles in Prevention Mental health providers and researchers emphasize the importance of medical providers having a holistic understanding of human trafficking as well as an appreciation for sub-populations requiring specialized attention. They point out the unique role health care providers can fulfill in terms of screening for individuals at risk for human trafficking. Social service providers affirm that individuals can be at risk for human trafficking as a result of a history of abuse, runaway tendencies, and low income or poverty, in addition to a variety of other factors. They acknowledge that physical and mental health providers are often privy to information crucial to effective prevention. For example, doctors or nurses who are aware of a minor’s history of physical, emotional, or sexual abuse can incorporate screening questions into their sessions to identify indicators of potential trafficking at early stages. School nurses aware of families needing additional financial resources could alert youth in those families to labor trafficking and ways to identify safe employment options. Mental health providers also suggested examining those sub-populations who are at risk for trafficking yet were not victimized to better understand what factors might be critical to preventing human trafficking. Factors Contributing to Identifying Victims and Providing Services Social service providers and medical professionals confirm a number of contributing factors can complicate identifying victims of trafficking and providing services to them. A common reason victims of human trafficking are not identified, and therefore do not receive proper care, is because these cases are misclassified. For example, many cases of sex trafficking, especially those in which victims are romantically involved with their traffickers, are identified as sexual or domestic violence cases. Cases of human trafficking are sometimes even processed as domestic violence cases in the court system. Social service providers anecdotally report this is partly due to limited awareness among law enforcement personnel, community service providers, and medical professionals about the scope of the definition of human trafficking. They assert first responders should be adequately trained about this issue so they can properly identify and respond to victims they encounter, including domestic victims. Symposium attendees described additional barriers to identifying and providing services to international victims of human trafficking. They reported that one of the largest barriers for this population is language. International victims often have limited or no understanding of English. Victims of labor and/or sex trafficking may have signed illegal contracts that they believe legitimize their circumstances. International victims seeking medical and social services usually require the assistance of a translator. Service providers indicate that in order to ensure international victims are properly identified and safe, independent, confidential translators must be available. However, medical and social service providers acknowledge this requirement can be extremely challenging, if not impossible, to meet. Even providers in New York City, which has many multi-lingual communities, noted difficulties in finding appropriate translators when non-English speaking clients present themselves. Additionally, language phone lines can be costly and uncomfortable for both clients and providers, and may not be able to provide translation for all  client languages. Lack of cultural competency by health care providers can also significantly hinder the effectiveness of medical care provided to international victims. Social service providers at the symposium emphasized that an important part of cultural competency is the understanding and use of alternative medicines. They report that international as well as some domestic victims of human trafficking often come from cultures in which folk healing, healing rituals, and secret societies are commonly accepted and used. For example, some African-based therapeutic systems subscribe to the idea that only practitioners belonging to secret societies are able to provide proper psychological treatment. Social service providers also note that cultural competency entails understanding the cultural and religious beliefs surrounding certain medical practices and procedures, such as consuming prescription drugs, using birth control, and undergoing abortions. Successfully working with and treating these clients calls for incorporating into treatment the medical techniques with which victims are familiar and comfortable. Social service providers describe this as being especially true for children who need a comfortable and supportive environment. They suggest that medical practitioners be able to make referrals to specialized providers if they are not familiar or comfortable with medical treatments used by certain populations. Illiteracy, and specifically health illiteracy, often hinders victim identification and proper medical care. Organizations working with victims of human trafficking point out that many victims, both international and domestic, are illiterate. Therefore, they may be unable to read pamphlets, posters, or other written materials providing important medical information. Additionally, as our culture becomes more dependent on technology to communicate, increasing amounts of information about social services and medical care are being disseminated through the Internet. Individuals who are illiterate, have limited or no understanding of the English language, and/or have no access to the Internet have increasingly less access to crucial information. The consequences of human trafficking on mental health cannot be overstated. Victims of human trafficking have experienced considerable trauma, some of which does not present itself until years later. According to mental health service providers working with this population, practitioners need to have specialized training to most effectively provide care to clients experiencing trauma. One of the unique aspects of human trafficking that can lead to significant trauma is the fact that these victims have been paid for the harm perpetrated against them. Monetary payment for forced labor and/or sexual services and the social normalization of prostitution often result in victims receiving conflicting and confusing messages regarding their experiences. Treating only physical symptoms without addressing the underlying trauma will not effectively help this population overcome their experiences. Attendees acknowledged that in order to address short- and long-term trauma, adequate health care coverage that includes mental health services is imperative for all victims. Practitioners from a variety of fields indicated that coordinated service delivery is essential to preventing re-victimization. Victims often experience significant co-morbidity of physical and mental health problems, which cannot be treated as if they exist separately. Health providers and social service agencies recognize the need to develop relationships and systems to better coordinate service delivery, especially for helping victims move from emergency services to long-term rehabilitation and stability. Communities that have successfully developed integrated service delivery systems should be studied and their best practices should be shared. Working with victims of human trafficking can be extremely draining on service providers. Mental health providers reported that compassion fatigue and vicarious trauma among service providers can dramatically affect services. Organizations and individual practitioners working with this population need to ensure they have the supports necessary to sustain their work on behalf of victims. Re-traumatizing victims within ostensibly “safe” institutions is a serious concern. For example, providers working with victims in juvenile detention centers and other public systems pointed out that victims may be re-traumatized within those systems. Similarly, social service providers reported that some international victims have been re-traumatized by systems that treated them as suspected terrorists. Mental health workers testified that the majority of victims within such public institutions have not had their trafficking experiences recognized as traumatic. They suggested training and education could help these systems learn how to work with victim populations in a way that is not re-traumatizing. Mental health providers noted the role of resilience, not only in preventing human trafficking but also in helping victims of trafficking deal with and overcome their trafficking experiences. They cited dissociative disorders and other mental health conditions as coping mechanisms victims adopt to survive their trauma. While the importance of resilience in helping victims of human trafficking is anecdotally recognized, the variation in the treatment outcomes of victims indicates the need for further research to better understand its role in victims’ ability to overcome traumatic experiences. Human Trafficking as a Public Health Issue The symposium not only focused on the health care needs of individual victims of trafficking but also the public health consequences of human trafficking. The majority of research on human trafficking as a public health issue has focused on its effect on the prevalence of tuberculosis, HIV/AIDS, and Hepatitis B. Social service providers working with victims near the United States-Mexico border recognize the significant threat of cross-border contamination among the populations they serve. Government officials reported working on cross-cultural collaborations to examine and reduce cross-border contamination. But both government representatives and social and health service providers agreed that more work is needed in this area. Training Physical and Mental Health Professionals One of the major outcomes of the symposium was the recognition that training the medical field on the issue of human trafficking is imperative to improve identification of, and service delivery to, victims. Health care and social service providers also acknowledged that simply training first-responder medical personnel, such as emergency room physicians or emergency medical technicians, is not sufficient; all medical professionals, including those working in other public systems such as the justice system, need proper training. Participants also agreed that special efforts should be made to ensure medical professionals serving marginalized populations, such as nurses and physician assistants working with needle exchange programs, also receive training about human trafficking. Training would assist with identifying and treating victims and enhance prevention so health professionals could identify clientele at risk for trafficking. An improved training strategy would integrate the issue of human trafficking into the general and continued education of medical professionals. A number of medical professionals suggested that various medical associations, such as the American Medical Association, American College of Obstetricians and Gynecologists, and American Academy of Pediatrics, should focus their attention and resources on the issue of human trafficking. Social service providers and medical professionals suggested incorporating human trafficking into continuing education courses with a focus on quality of care, safety issues, and potential malpractice. Others suggested incorporating the topic of human trafficking into the larger issue of patient experience with violence and abuse. Social service agencies have had some success in working with associations. However, they understand medical associations took significant time to recognize domestic violence as an issue, and are committed to continuing work with associations to gain attention for human trafficking. Social service providers and medical professionals also discussed adding human trafficking to the standard educational curricula of doctors, nurses, social workers, psychologists, and other health professionals. They suggested creating a comprehensive human trafficking curriculum that could be adapted and used by a variety of institutions and audiences. The curriculum could be augmented by more specialized, targeted curricula, for example curricula specifically for emergency room nurses. Attendees identified a variety of existing training tools for the medical field, but believed developing a standard human trafficking curriculum would be valuable. Attendees discussed who would be best equipped to provide training on human trafficking to the medical field. Medical professionals and social service providers agreed the training should be conducted by a peer (e.g., a nurse would train other nurses). However, they also acknowledged that the demand for training of medical professionals is much greater than the number of qualified medical professional trainers. Social service agencies offered examples of how they have successfully trained medical professionals. They noted that social service providers can sometimes present a more comprehensive perspective on the array of issues trafficking victims face. Social service providers also suggested having victims participate in training, enabling health care professionals to learn first-hand about their experiences. Educating the Public In addition to educating health care professionals, symposium attendees discussed the importance of educating the broader public, including individuals in other professions who may encounter this population. Human trafficking has received greater media and public attention; however, attendees noted that the majority of people in the country remain unaware of this problem, especially as it relates to labor trafficking and domestic victims. Social service professionals reported coming into contact with people from all walks of life who may have witnessed instances of human trafficking but lacked the proper information or resources to recognize it. They expressed the need for further and ongoing public education and awareness building to successfully address human trafficking. Research and Data Ongoing research and comprehensive data regarding the health care needs of, and services available to, victims of human trafficking can help ensure services meet their health and mental health needs. Medical professionals, social service providers, and researchers in the anti-trafficking movement expressed concern that no data tracking systems exist to accurately evaluate current health service delivery systems for victims of human trafficking. They noted this deficiency at both the local and national levels. Social service providers agreed lack of data not only hindered assessment of services they provide, but also impeded funding to enhance services as government and non-government funders request data to demonstrate victims’ needs for services and agency needs for financial support. Yet they cannot obtain data without funding to build data infrastructure and conduct research. One health care provider working with this population suggested instituting a public health task force to assist with data collection for victims’ services. Social service providers and researchers affiliated with universities reported working jointly on research projects to assess health needs and services for victims of human trafficking, but they agreed that an overall infrastructure for data collection is lacking in the anti-trafficking field. All attendees acknowledged that data collection is an enormous challenge given service providers’ limited time availability and lack of expertise in developing and implementing data collection systems. In addition to data collection and evaluation of services, symposium attendees identified other areas in which further research is needed: Demand reduction programs Societal factors promoting solicitation of commercial sex Typologies of traffickers Typologies of the consumer or end user (e.g., “johns,” employers) Economic factors involved in trafficking Health consequences of labor trafficking in the United States Financial impact of human trafficking in terms of health and mental health services Public health impact of human trafficking in the United States Role of resiliency among victims Protective factors for vulnerable populations Best practices for treating victims of human trafficking Attendees agreed that human trafficking is more likely to be eliminated or reduced if the motives of traffickers and other exploiters (e.g., johns, employers, relatives) can be understood and their activities prevented. They also cited the importance of integrating public awareness and corporate responsibility into preventing labor trafficking. Representatives of anti-trafficking organizations and service providers working with trafficking victims commented that they were not fully aware of best practices being implemented by other anti-trafficking organizations and recommended an improved infrastructure for sharing information. They suggested starting with a listserv that included symposium attendees to begin building a community of practice for information sharing. Human Trafficking and Related Fields While human trafficking has an extensive history, the Federal government only recently enacted the TVPA, which established new programs and services for victims of human trafficking. Accordingly, symposium attendees recognized that the anti-trafficking field can learn significant lessons by examining best practices and advances in similar fields, including domestic violence, child sexual abuse, victims of torture, and refugees. Medical providers observed that several best-practice models have been created and implemented in the United States and a number of suggestions presented at the symposium have been successful in other fields. Social service providers and government representatives also encouraged building coalitions and partnerships between those in the anti-trafficking field and individuals and organizations in related fields in order to share information, ideas, and resources. Anti-trafficking service providers believed services currently are provided within distinct categories in which an individual is treated as a refugee, victim of torture, or victim of human trafficking, as opposed to an approach that is based on a more inclusive, multi-dimensional framework. Attendees felt an integrated, multi-dimensional approach was especially important for law enforcement and prosecutors whose mandates tended to encourage them to investigate and prosecute cases within strictly defined guidelines and parameters. Coalitions and stronger partnerships would assist in creating a multi-dimensional, victim-centered framework of service provision and would help reduce duplication of services. Anti-trafficking representatives from Florida noted they have begun implementing a multi-dimensional framework in their trainings, which has helped service providers from various backgrounds compare and contrast human trafficking needs and services across related fields. Symposium participants recommended greater collaboration among service providers and agencies in various fields and encouraged improved and increased data collection among government agencies addressing human trafficking. Conclusion The National Symposium on the Health Needs of Human Trafficking Victims provided a unique opportunity for members of the anti-trafficking community and health care professionals to begin discussing ways to improve identifying and providing services to human trafficking victims in medical settings. Participants identified specific ideas, contacts, and next steps that could build on the relationships established and lessons learned at the symposium. As with efforts to provide effective services to victims of crime, violence, and abuse, participants recognized both the progress that has been made and the steps that still need to be taken. Addressing the Needs of Victims of Human Trafficking: Challenges, Barriers, and Promising Practices August 2008 By: Heather J. Clawson and Nicole Dutch I. Study Overview This is the fifth in a series of Issue Briefs produced under a contract with the U.S. Department of Health and Human Services (HHS), Office of the Assistant Secretary for Planning and Evaluation (ASPE), to conduct a study of HHS programs serving human trafficking victims. Funded in the fall of 2006, the purpose of this exploratory project is to develop information on how HHS programs are currently addressing the needs of victims of human trafficking, including domestic victims, with a priority focus on domestic youth. This project also reviewed relevant literature, and identified barriers and promising practices for addressing the needs of victims of human trafficking, with a goal of informing current and future program design and improving services to this extremely vulnerable population. This issue brief focuses on the needs of victims of human trafficking and the services available to meet those needs. Additionally, it discusses challenges and barriers to providing services to victims, international and domestic, adults and minors, and highlights innovative solutions to these challenges and promising practices to overcome barriers. Throughout the brief we make distinctions, where appropriate, between international adult victims, international minor victims, and domestic minor victims. No information was available regarding domestic adult victims as agencies did not report providing services to this population. There also is no current research or literature providing information on serving this population. II. Understanding the Needs of Victims of Human Trafficking Common Needs When service providers and law enforcement personnel were asked to describe the needs of victims of human trafficking, a common response was, “what don’t they need.” The table on the next page shows the responses given by those service providers participating in the study.(1) The safety needs of victims were identified as the first priority by all of those working with victims. According to law enforcement and providers, screening for safety needs (for both the victims and providers) is part of every assessment they conduct. Safety needs are often met when the next priority need for (safe) emergency housing is addressed. Other emergency needs include food and clothing and, for international victims, translation services to avoid feelings of isolation and to facilitate communication regarding other needs. Once emergency needs are met, other needs that present themselves in the short- and long-term need to be met. These include housing (transitional and permanent for adults, and foster care or permanent placement for minors), legal assistance (e.g., help in understanding legal rights, legal representation and, for international victims, assistance with filing T-visa applications, and immigration petitions), and advocacy (e.g., assistance retrieving identification documents, completing applications, attending appointments, and navigating the different U.S. systems, including criminal justice, child welfare, immigration, human services, transportation, etc.). Additionally, service providers and law enforcement note that most victims also need health screening (tuberculosis, sexually transmitted diseases, pregnancy), vaccinations/immunizations, medical treatment for physical injuries, and dental care. Other service needs include child care (for both adults and minors with children), education (GED assistance, enrollment in school, technical training/certification), life skills training (including assisting some international victims with operation of basic household appliances, using public transportation, using a telephone, mailing a letter, etc.), job training, finding employment, financial management, and where appropriate, family reunification or repatriation. In addition to the above service needs, service providers report that all victims of trafficking have some type of mental health need.Specifically, service providers indicated that as a result of the trauma experienced, victims need trauma counseling and for domestic minor victims in particular, they often need anger management, conflict resolution, and family counseling.                                                     Needs of Victims of Human Trafficking   International Domestic Minors Adults Minors Emergency Safety X X X Housing X X X Food/Clothing X X X Translation X X   Legal Guardianship   X X Short-/Long-term Transitional housing X   X Long-term housing X   X Permanency placement   X   Legal assistance X   X Advocacy       Translation X X X Medical care X X X Mental health/counseling X X X Substance abuse treatment     X* Transportation X   X Life skills X X X Education X X X Financial assistance/management X   X Job training/employment X X X Child care X X X Reunification/repatriation X X X * While substance abuse treatment may be a need for international victims, it was only identified as a need for domestic minor victims Differences in Needs While the needs are relatively similar regardless of whether someone is an international or domestic victim, adult or minor, one point is clear-the magnitude of these needs varies for each victim depending on his or her circumstances. For example, international victims often express a greater and more urgent need to obtain employment than domestic victims do. This is reportedly the result of their desire to send money back home to support their families. Additionally, while obtaining identification documents (e.g., passports, birth certificates, driver’s licenses) is reported to be an important need for all victims in order to access services, it is especially important for international victims to have some form of identification or legal documentation on hand. One service provider told of an incident where a client was removed from public transportation and placed in detention because the client did not have any identification on his/her person and had not yet received his/her certification letter indicating he/she was a victim of human trafficking. This experience exacerbated the client’s situation and need for ongoing legal assistance. Legal assistance is one other area where there are differences in degree or type of need between international and domestic victims. While both have legal needs, international victims, often in the U.S. illegally, have more complex legal needs usually related to their immigration status. This includes needing representation at deportation hearings, assistance with applications for T visas and derivative visas, and renewal applications. While it is not necessarily unique to domestic victims, service providers report that domestic victims often present with serious substance abuse issues. Some providers report that while international victims also need assistance with similar problems, they are less likely to admit they have a problem out of shame, fear of stigma, or denial that their substance abuse constitutes a problem. In some cases, the service providers do not want to indicate this as a need of international victims for fear access to treatment records will be subpoenaed and used against the victim in a legal case (criminal, civil, or immigration). Regardless of the victim, law enforcement and service providers stress that it is not so much the type of needs that vary by victim, but the duration of services required to address those needs and the level of difficulty obtaining such services. III. Services Available for Victims of Human Trafficking Prior to the passage of the Trafficking Victims Protection Act of 2000 (TVPA), law enforcement and service providers report struggling to piece together the comprehensive services needed by international victims of human trafficking with scarce resources. Under the TVPA, HHS was designated as the agency responsible for helping these victims of human trafficking become eligible for benefits and services and funds were allocated for the delivery of such benefits and services. One responsibility of HHS is to certify adult international victims of trafficking who are not U.S. citizens or legal permanent residents (LPRs) once they are identified. This certification allows adult international victims to receive the same benefits and services available to refugees. U. S. citizens or LPRs who find themselves victims of trafficking (i.e., domestic victims) do not need to be certified in order to receive benefits. In the case of citizens, they are already eligible for many benefits and services they might need. And although LPRs face greater benefit restrictions than U.S. citizens, they do not face the same eligibility restrictions as undocumented immigrants, which is usually the status of international adult victims when they are first identified. International minor victims of trafficking (under the age of 18) do not need to be certified but instead receive a letter of eligibility from HHS and are then eligible to apply for a similar range of services as refuges, including the Unaccompanied Refugee Minor (URM) Program. The Unaccompanied Refugee Minor (URM) Program for International Minor Victims International minors who are determined to be victims of human trafficking by law enforcement officials are eligible for the T visa, which allows victims of trafficking to remain in the U.S. and become eligible for work authorization. Additionally, international minor victims without a parent or legal guardian in the U.S. are eligible for services under the Unaccompanied Refugee Minors (URM) program. The URM serves as a legal authority designated to act in place of the child’s unavailable parents. Children are placed in foster homes, group homes, or independent living arrangements. Through the URM, children can receive intensive case management, education, health care, mental health counseling, independent living skills training, assistance with family reunification and repatriation, and other services until they turn 18 or such higher age, depending on the foster care rules of each state. In order for an international adult victim of trafficking to receive certification he or she must first be determined to be a victim of a severe form of trafficking as defined by the TVPA and he or she must be willing to comply with all reasonable requests to assist law enforcement in the investigation of the trafficking case (minor victims are exempt from this requirement). Following this determination, the victim must complete a bona fide application for a T visa, receive a T visa, or be granted “continued presence” by federal law enforcement. T visas were established under the TVPA and allow victims of trafficking to become legal temporary residents of the United States. Once a T visa is obtained, a victim may remain in the U.S. for up to three years. At the end of this time period the victim may be eligible for legal permanent residence status. Certified adult victims are eligible to receive federally funded services and benefits similar to refugees. Some of the services that victims of trafficking are eligible for through federally funded programs, such as the Per-Capita Victim Services Contract include housing or shelter assistance, food assistance, income assistance, employment assistance, English language training, health care assistance, and mental health services. Per-Capita Victim Services Contract The Per-Capita Victim Services contract is designed to centralize services while maintaining a high level of care for victims of human trafficking through “anytime, anywhere” case management. Working in concert with HHS’ ongoing Rescue & Restore public awareness campaign, subcontractors are reimbursed for the services actually provided to each human trafficking victim. The contract also streamlines support services in order to help victims gain timely access to shelter, job training, and health care. For more information, please contact mrs@usccb.org Prior to becoming certified, a period referred to as pre-certification, victims pursuing certification and cooperating with law enforcement can receive limited, often emergency services, which parallel most certification services as a result of funding available from HHS and other federal agencies. Pre-certification services include housing, food/clothing, advocacy, legal assistance, medical/dental care, language services (e.g., interpreters/translators), mental health counseling, education, and job training. In addition, service providers report seeking other assistance for victims who may decide not to cooperate with law enforcement out of fear of retaliation from the traffickers, or for other reasons. The strategies to assist these victims may include seeking asylum for the victim or filing for a U-Visaand accessing services under the Violence Against Women Act, or for some agencies, tapping into non-federal or unrestricted funding streams to provide ad hoc services (for example, from state or local government programs, foundation-funded programs, etc.). IV. Challenges and Barriers to Meeting the Needs of Victims While there seems to be consistency between the needs of trafficking victims and the services for which they are eligible and the programs in place to provide these services, there are many challenges and barriers to getting victims into service. Lack of Knowledge and Understanding. One of the most common and frustrating challenges reported by law enforcement and service providers is the lack of knowledge and understanding regarding human trafficking among service providers, law enforcement, and even victims themselves who often do not believe or understand that they are a victim of crime. As a result, victims often go unidentified and unserved. Lack of knowledge and understanding of what services are available is a barrier for service providers as well. Many service providers report their own confusion regarding what services their clients are eligible for and can access, which highlights the need for effective case management as identified in a previous Issue Brief. “There is a general lack of knowledge and understanding of human trafficking and not enough service providers in the healthcare profession, local Social Security Administration offices, department of motor vehicles, and other key agencies are trained on this issue and know they can serve these clients. We are constantly having to take our clients to appointments because they are turned away when they try on their own.” Service Provider Availability of Services. Even though victims, international or domestic, may be eligible for services, the availability of those needed services is often limited due to long wait lists and associated fees (even if offered on a sliding scale). As one provider indicates, “Free clinics are not always free. You spend a lot of time waiting to be seen and there are often some unexpected charges associated with most services.” According to service providers, this is particularly true for mental health services and substance abuse treatment. While accessing basic medical services (physicals, gynecological exams, screenings, etc.) is not reported as a problem for most service providers (with the exception of some providers in rural communities), accessing specialized medical treatment was problematic. Specifically, specialized care for acute, long-term needs, such as diabetes, cancer, and other illnesses, including prescriptions that are part of the treatment, were often cost prohibitive and in some cases, exhaust program resources. “As a service provider, I find it confusing trying to figure out what services are available for which clients [international or domestic]. Most of my time is spent making calls or running around to agencies. We [service providers] need a road map that helps explain not only what services our clients are eligible for but how we go about accessing these services. What documentation does my client need? What paperwork do they need to fill out? What would make my client ineligible for services? I can barely navigate through all of these systems myself, so how can we expect our clients to take this on?” Service Provider Similarly, while most service providers are able to find basic dental care for their clients (although sometimes there are long waiting periods), more serious and costly dental procedures, such as root canals and extractions, are difficult to obtain. Housing is another service that law enforcement and service providers report is limited. While finding emergency shelter for women and girls is not usually a problem, finding the same placements for men and boys is difficult. Transitional and permanent housing is scarce for everyone but in particular for domestic minors with felony convictions and victims with mental health or substance abuse issues. “There just isn’t affordable housing in our community for anyone. We often end up placing groups of victims together in apartments or houses. Sometimes this works but sometimes the only areas where they can afford housing are high crime areas. We’ve actually had clients become the victims of other crimes (burglary) because they could only afford to live in unsafe neighborhoods.” Service Provider Finally, the availability of services in general for domestic victims is viewed as problematic by some service providers. As one provider states, “If you just look at what domestic victims are eligible for on paper, it looks promising. However, trying to access those services is another story.” Several examples include referrals to child welfare agencies by service providers and law enforcement only to find out that the agencies would not see the domestic victims because the abuse did not occur at the “hands of a parent or legal guardian.” In these cases, providers and law enforcement report minors falling through the cracks of the mainstream system and not receiving services. In some cases, minors were handed back to their abusers and “turned back out on the streets.” Appropriateness of Services. Service providers talk not only of the need for more culturally appropriate services, but also for gender appropriate services. Finding such services can be challenging, particularly in rural communities. Additionally, service providers stress the importance of understanding what is meant by culturally appropriate services. For instance, just having someone from the same culture who speaks the same language does not translate into culturally appropriate services according to service providers. Speaking the same language as clients can help facilitate service provision but that is just one piece of one’s culture. Service providers gave examples of victims of sex trafficking who were not comfortable talking about their experiences with someone from their same culture out of the associated shame and stigma. Other examples given by service providers were related to the gender and culture of the victim. For example, in some cultures, it is not appropriate for a female to visit a male doctor. Recognizing these challenges and the implications for providing appropriate services to clients is seen as critical by providers themselves. The appropriateness of services also extends to examining the culture of the environment in which the service is offered. For example, service providers note that providing services to victims who are living in shelters can be difficult and some environments can result in “revictimization.” In particular, providers share examples of sex trafficking clients being placed in domestic violence shelters and then facing humiliation and isolation. For international sex trafficking victims, the isolation is usually attributed by service providers to language barriers and cultural differences. But for domestic victims of sex trafficking, the humiliation and isolation, according to service providers and some victims, is attributed to perceptions that domestic victims are “prostitutes,” or willing participants, rather than victims of abuse and crimes. These misperceptions reflect again, a general lack of understanding and knowledge of the issue, not only among service providers but in the general public. Access to Services. The two greatest barriers to accessing services for international victims include language barriers and transportation. Service providers indicate that the availability of information and access to providers that speak English, Spanish, and in some communities Korean, is not difficult. It is their clients that speak other languages that have difficulty accessing services. Additionally, transportation is a problem. In large cities, teaching clients how to use the transportation system can be overwhelming and very time consuming. Service providers report clients missing appointments because they were afraid to use public transportation. In smaller communities, there is often limited or no public transportation, also making it difficult for clients to get to appointments. “There is no cookie-cutter approach to working with this population. Males, females, adults, children, sex trafficking, or labor trafficking. You just don’t know how long you will be working with them. Just when you think they are moving forward, something happens with their case or with their family or they see something in the news that triggers the trauma experience and sets them back sometimes months in their progress. A lot of times it is one step forward and two or three steps back. You just have to be prepared for setbacks.” Service Provider Length of Services. Another challenge identified by service providers and victims themselves is the length or duration of the services available to victims. Service providers note that the timeline to self-sufficiency varies by client. Some clients may come in, get certified right away and be ready to work, especially among many labor trafficking victims. Other victims, however, may remain pre-certified for a longer period of time and even after becoming certified, they may not be ready to work or move forward with their lives. According to service providers, individual timelines are difficult to predict. However, with close monitoring and anticipation of set-backs (e.g., depositions, appearances at trial, intense counseling sessions, reunification, etc.), providers are able to adjust services to meet the changing needs of clients. For domestic minors, shelter stays are often limited to 15-, 30- or 90-days and do not allow providers enough time to establish relationships with victims or provide adequate services to meet their longer-term needs. Transitional housing for domestic minors and domestic victims is often limited, and when available victims often find it difficult to follow the rules/restrictions of the facilities (e.g., no drug/alcohol use, required employment). “When working with a domestic victim, I just need more time. I can’t stabilize a client with an extensive trauma history within 90 days or transition them to permanent housing within 18-months. Many of my clients struggle to get clean, get an education (or GED), learn life skills, obtain employable skills, and get employed. This is especially true if they have not begun to work on trauma recovery and this can take years.” Service Provider   Lack of Coordination of Services. For the most part, service providers acknowledge improved coordination of services for clients over the past several years. However, they see the need for a single point of contact within each agency working with victims and a central case manager to ensure communication and coordination of services. This appears to be especially true in the case of minor victims. According to service providers and law enforcement, when working with minor victims, in particular international minor victims, there are often numerous individuals involved in a case, making coordination and communication difficult. In some cases, providers and law enforcement report not knowing who to contact on behalf of the minor or who could make decisions on behalf of the minor. There were cases of information not getting transferred from one agency to the next, sometimes resulting in minors not getting the services they needed. As one provider states, “When the process for [international] minor victims works, it works well. But when it doesn’t, it fails miserably.” There is agreement among providers and law enforcement alike that there needs to be more information and communication regarding how international minor victims are served. Most providers report positive experiences with the URM programs but communications from these programs, as well as the availability and location of services are seen as limited. V. Innovations and Promising Practices to Serving Victims To address the many challenges and barriers to providing services to victims of human trafficking, many service providers have developed innovative strategies and promising practices for their agencies and their clients. Collaboration. The importance of collaboration in meeting the needs of victims of human trafficking cannot be overstated. Law enforcement and service providers stress the importance of working together to meet the diverse and complex needs of this population. The establishment of coalitions and task forces, such as the ORR-funded Rescue and Restore coalitions, is viewed as one strategy that has resulted in the increased availability of services for all victims. “We have partnered with Goodwill and other similar organizations to obtain vouchers for our clients. They are able to use these to shop for necessities. It provides them with what they need as well as gives them some level of independence.” Service Provider Several service providers report establishing formal memoranda of understanding (MOUs) with domestic violence shelters to ensure not only placement of their clients but placement in a facility with a staff trained on human trafficking and sensitive to the needs of victims. These MOUs are also important because some domestic violence shelters will not (or cannot) accept victims if they are not victims of domestic violence, defined as involving a boyfriend or spouse. But with MOUs, exceptions to this definition have been made with some agencies. Service providers also report success in reaching out to domestic violence shelters that traditionally serve battered immigrant women. In several communities across the country, collaboration among local law enforcement, juvenile and family court judges, child protection services, and youth shelters and programs has proven to be a promising and necessary practice for identifying and meeting the needs of domestic minor victims of sex trafficking. Consistent Case Managers. Given the complexity of victims’ needs and the comprehensiveness of the services provided, service providers, law enforcement, and victims report that having a consistent case manager all the way from identification to case closure is a promising practice.(7) While not possible in all cases due to staff turnover and the lack of funding for case managers for domestic victims, having this consistency benefits the victim, service providers, and law enforcement (including prosecutors). A central case manager with knowledge of all aspects of the victim’s situation can ultimately save time and resources. “Victims need to be assigned a case manager from point of identification throughout the criminal justice process. This person does not need to be a victim witness coordinator from law enforcement (although they could) but the person needs to be consistent.” Law Enforcement Mobile Services. In some communities, home visits that provide medical and mental health care, and basic case management, is an innovation helping to meet the needs of victims. This approach is especially valued by agencies serving clients in large geographically dispersed areas, as well as rural areas. In both of these cases, clients can find it difficult to get to their appointments. Some service providers mention using in-home visits as a way to introduce clients to services; it is almost a trial period before transitioning them to in-office treatment. Additionally, linking clients to existing mobile health clinics is a common practice for many agencies, including shelters working with domestic victims. Use of Pro Bono Services. Several agencies report using pro bono services, particularly for legal services. This often involves providing training to attorneys on the issue of human trafficking and providing access in order to interview clients. While this results in a larger pool of affordable and appropriate service providers for clients, it does require significant training and monitoring according to providers. One example of where this approach has worked well is Project Liberty, highlighted in the box below. Volunteer Programs. Some agencies establish programs where their clients can do volunteer work. Because many victims are unable to do regular work until they receive their work authorizations, service providers need to find ways to use this “waiting period” to help engage their clients in the community and workplaces, when appropriate. Several providers have in place volunteer programs where clients gain valuable on-the-job training that can then result in quick placement in a job with the same or similar agencies. VI. Summary The needs of victims of human trafficking, whether international or domestic, can be characterized as complex, requiring comprehensive services and treatment that span a continuum of care from emergency to short-term to longer-term assistance. Providing these services can take months or years; the timeline for serving each victim is different and often unpredictable. The challenges associated with accessing timely and appropriate services for victims are ongoing. But through collaboration among agencies, including non-governmental organizations, shelter providers, health care providers, law enforcement and others in communities across the country, and through innovative strategies and promising practices, there are more services available today for victims of human trafficking than at any time in the past. And while there remains room for improvement, particularly regarding adult domestic victims, the services available to victims of human trafficking appear to be better tailored to their needs than they have been in the past. Building Bridges Between Domestic Violence Organizations and Child Protective Services By Linda Spears Acknowledgments I am first and foremost grateful to all who participated in the preparation of this paper for their commitment to the principles of collaboration between domestic violence and child protection. Their skill in working together allowed me to write a paper that reflects these values both in its content and its preparation. My deepest gratitude is extended to Susan Schechter, of the University of Iowa School of Social Work, for her thoughtful guidance in conceptualizing and completing this work. I am equally grateful to Jill Davies, of Greater Hartford Legal Assistance, for authoring the case narrative and for her substantive edits to the documents. Their efforts brought greater clarity and utility to the paper. I would also like to thank my colleagues for their contribution of source materials and their review of the many drafts along the way. Their creative energy and technical assistance were invaluable. Chief among them are The Honorable Len Edwards of the Santa Clara County Superior Court; The Honorable Bill Jones of the District Court of Charlotte, NC; Merry Hofford of the National Council of Juvenile and Family Court Judges; Janet Carter of the Family Violence Prevention Fund; and Lonna Davis and Pamela Whitney of the Massachusetts Department of Social Services. I would also like to acknowledge the leadership of Anne Menard, at the National Resource Center on Domestic Violence, under whose auspices this document was developed. Finally, I am deeply appreciative for the support of The Ford Foundation, whose continued commitment to ending family violence made this work possible. About The Authors Ms. Spears is the Director of Child Protection at the Child Welfare League of America, where she directs both its national child protection reform initiative Protecting America's Children: It's Everybody's Business, and the City/County public child welfare efforts. Prior to joining CWLA in 1992, Linda served as the Director of Field Support with the Massachusetts Department of Social Services. As a member of the department's senior management team, she was responsible for agency-wide services in family preservation, child protection, domestic violence, out-of-home placement, permanency planning, child care, independent living, substance abuse, and housing. While in Massachusetts, Ms. Spears led an effort to better integrate the expertise of domestic violence advocates with the work of child protection caseworkers. She is a member of the board of directors of the Family Violence Prevention Fund, on the advisory committee of the National Resource Center on Child Maltreatment, and an advisor to the National Resource Center on Domestic Violence, Child Protection and Custody. TABLE OF CONTENTS I.    Introduction II.    Why Must Domestic Violence Advocates and Child Protection Staff Work Together? III.    What Effects Does Domestic Violence Have on Children? IV.    How Does the Child Protection System Work? How Did the Child Protection System Begin? How Do Cases Move Through the Child Protective Agency? V.    How Can Domestic Violence Organizations and Child Protection Agencies Collaborate? Examples of Current Domestic Violence/CPS Collaborations What Would a Collaborative Response Look Like? Principles for Domestic Violence-Child Protection Collaboration VI.    Conclusion Introduction Violence against women and children is centuries old, but only over the past 25 years have communities made significant improvements in their responses to each problem. In the 1970s, state legislatures created systems to help abused children, and by the 1980s many grassroots women's organizations had set up shelters for battered women. These two response systems were designed with very different mandates, funding, and goals. As a result, tensions and problems now emerge as service providers, the courts, and communities try to more effectively help those families in which violence against women and children is overlapping and intertwined. Domestic violence advocates have learned that the concerns of battered women are inextricably linked to the welfare of their children and that the safety decisions of battered women are typically guided by the needs of their children. As a result, domestic violence organizations have worked hard to address the needs of the children of battered women, including providing a variety of concrete services like children's play and educational groups, support activities, and therapeutic services. Advocates have also broadened the scope of their work to include case-level and systemic advocacy for children. Over the last ten years, domestic violence advocates have learned that it will take a coordinated effort to effectively protect women and their children. No single organization can do this work by itself. Without collaboration and coordination among agencies, it is the battered women and their children who pay the price: their safety is jeopardized and their needs for security and stability are compromised. "Building Bridges Between Domestic Violence Organizations and Child Protective Services" was prepared as a new resource for advocates seeking to strengthen efforts to help battered women with abused and neglected children. This paper provides both background information and a framework for collaboration with child protection agencies that will support the work of domestic violence advocates as they try to improve safety for women and their children. The paper covers the following topics: Why must domestic violence advocates and child protection staff work together to keep battered women and their children safe? What effects does domestic violence have on children? How does the child protection system work? How can domestic violence organizations and child protection agencies collaborate effectively and respond to policy challenges constructively?   Last night Gina's boyfriend Mark came home drunk again. They started arguing about money, and Mark slapped and punched Gina. Seven-year-old Sammy ran into the kitchen and started hitting Mark and yelling, "Stop hurting my Mommy!" Mark picked Sammy up by the seat of his pants and yelled, "Stay out of this, you little bastard, you're just like your father - a real loser." He then dropped Sammy, who crashed to the floor. Sammy started crying, and Gina yelled at him to get out of the kitchen. Gina and Mark's one-year-old daughter Jessie started crying in the other room. Mark told Gina to just "let her cry, or she'll grow up to be a stupid baby like you." A neighbor called the child abuse hotline to report that there was fighting in the apartment next door and that she could hear the children crying again and worried that they were being hit. Gina's situation is all too familiar to domestic violence advocates and child welfare workers. A woman is the victim of physical assaults and verbal abuse. Her children's lives are altered by her situation - their well being, and often their safety, are compromised by the actions of an abusive partner. Sometimes, before the woman can fully consider the alternatives available to her, she is reported to child protection authorities because neighbors, friends, or service providers are concerned that the risk to her children is too great. Soon, she finds herself meeting with a child protection caseworker whose assessment of her situation could result in the removal of her children. The actions of the police, child protection workers and others can have a tremendous impact on the immediate and long-term safety of both Gina and her children. However, domestic violence advocates and child protection workers might start from different places of emphasis. For example, advocates considering Gina's situation might focus on the following questions: How does Gina view the risks to herself and her children? What supports and resources does Gina have available to help her keep herself and the children safe? What is her current safety plan? Will it be effective, or does she need additional information and resources? How dangerous is Mark? Does he understand how he is hurting Gina and the children? Has he ever been arrested for his violent behavior? How did he respond? Will he obey court orders? A child protection worker might focus on these questions: What happened on the night of the incident according to Gina, her children, and the neighbor? Was Sammy physically injured when Mark dropped him? If so, did Mark or Gina make sure he got medical attention? Has this happened before? Has Mark every hit Sammy or Jessie? What steps has Gina taken to protect the children? Can Gina protect the children? Are there other indications that the children are neglected or abused or at serious risk of harm? Once advocates and caseworkers answer these questions, each will begin a series of activities to help family members achieve safety. These efforts are likely to help some family members. For example, a battered woman's shelter will provide safety for mother and children in the short term. However, once the shelter period is over, lack of resources may send her back to an abusive partner, placing her and the children at renewed risk. At the same time, foster care placement - arranged through the child protective system - can provide safety for the children, but it may not be needed or desirable if the mother is able to provide for their care. Even if she can't, foster care does nothing to address her safety concerns. Family preservation workers can also provide a valuable resource to the family, with frequent home visits to provide help and monitor the safety of mother and children, even if the abusive partner returns. But this intervention can be problematic if the family preservation worker does not have strong skills in handling a domestic violence situation. Finding strategies that help both women and children to be safe is a dilemma that challenges domestic violence advocates and child protection workers every day. Despite mutual interests, those working with battered women and their children find that not all approaches are useful in achieving safety for all victims. Some approaches don't last long enough. On occasion, interventions to help one victim - giving the mother time to develop a plan - might actually increase the risk to another group of victims, the children. When advocates and child protection workers are able to effectively assist women and children, it is likely that they have done so by coordinating safety assessments and interventions for both the mother and child. Together, they have also found ways to better understand how services for battered women and their children work, and how these services can work together. This has meant sharing vital information about the differing laws that guide domestic violence advocates and child protection caseworkers, the values and principles that guide their responses, and the tools and resources that are available in each system. For advocates, collaboration can mean a significant and positive change in their work on behalf of women and children. Child protection workers are not experts in domestic violence. Typically, they must have general casework skills to deal with a variety of family needs. Only a few workers have training opportunities that would allow them to develop expertise in the dynamics of battering and its impact on children. While most are familiar with local battered women's shelters, they often have limited information about the range of related services and supports that are available through advocates, the courts, and other systems. Domestic violence advocates can change this through collaboration. Likewise, advocates can be frustrated in their interactions with a child protection system whose powers are substantial and whose rules may often seem arbitrary and subjective. Collaboration can help unravel the complexity of the child protection system to reveal ways in which advocates can work effectively with child protection workers to keep both battered women and their children safe.   Author's Note: CPS is the acronym commonly used to denote the public agency designated by statute to investigate reports of child abuse and neglect. In this paper, the terms cps, child protective agency, and child protection agency are used interchangeably. The term child protection system is used to denote the broad network of partners with critical roles in child protection including the legal system, the cps agency, and other service providers. For advocates to collaborate effectively with child protection workers, the latter must have a basic understanding of the effects of domestic violence on children. For more than a decade, researchers have examined the impact of children's exposure to domestic violence. This body of data supports the experience of women like Gina. Most children who live with domestic violence witness it in some form, and this experience may cause harm. These harms include those that result when: children experience their mother being battered and also see injuries that result from the violence; children are injured during a violent episode; this may occur inadvertently when a batterer attacks, a victim tries to defend herself or the children, or the child tries to protect a parent; or children are directly abused or neglected.1 While effects on individual children may vary, researchers have concluded that many children who are exposed to violence exhibit at least some symptoms related to this experience. These symptoms might include fearfulness, sleeplessness, withdrawal, anxiety, depression, and externalized problems such as delinquency and aggression.2 Research also suggests that these problems are often alleviated when children and their mothers are offered adequate social, emotional, and material support and safety. The Overlap of Domestic Violence and Child Maltreatment Through their work with women like Gina, front-line workers in domestic violence and child protection agencies are increasingly aware that when there is child maltreatment there is often domestic violence. Data from research and from direct practice in shelters and in child protective service programs are supporting their experience. In one nationwide survey of 6,000 families, researchers found that 50% of men who frequently assault their wives also frequently abuse their children.In a 1991 Boston City Hospital study, researchers reported that 59% of mothers of abused and neglected children had medical records that suggested that their partners had battered them. Although there is little formal research on domestic violence in child protection caseloads, some data support a link between domestic violence and child abuse and neglect. For example, in a 1990 review of substantiated child protection cases, the Massachusetts Department of Social Services reported that workers noted domestic violence in 30% of the cases.Because the agency did not prepare or require caseworkers to consider domestic violence in the investigation and assessment process, the study was believed to underestimate the actual incidence of domestic violence. In a subsequent study, conducted after implementing policies and training in domestic violence, the Department found that in 48% of records reviewed workers identified domestic violence or cited "protecting an adult from domestic violence" as a goal of service. As with any case type, domestic violence cases can range from those where child maltreatment is highly unlikely to those in which there is serious or life threatening harm to children. Thus far, several other child protection agencies have documented a disturbing link between domestic violence and fatal child abuse. In 1993, the Oregon Department of Human Resources reported that domestic violence was present in 41% of families experiencing child abuse and neglect resulting in critical injuries or death.The Massachusetts Department of Social Services made a similar finding when a 1994 review of child abuse- and neglect-related fatalities revealed that 43% of mothers identified themselves as victims of domestic violence.In New York City between 1990 and 1993, the public child welfare agency found that 55.6% of the families with child homicides had a documented history of domestic violence in the four years preceding the fatality. Although we are learning more about the connection between domestic violence and child maltreatment, we still know little about how the two interact within the family. There is no evidence, for example, that fatal child abuse is more likely to occur where there is domestic violence. A better understanding of domestic violence will help child protection workers to best target their interventions. Also, if advocates and child protection workers strengthen their knowledge and skills in assessing the risk to children, they will be better able to reduce the number of children and women experiencing serious harm. The child protection movement began more than 100 years ago and galvanized around a highly publicized New York City case involving a young child, Mary Ellen, who was brutally beaten by her caretakers. This case led to the creation of the first child protection agency and state statute providing agents to conduct court investigations into child maltreatment.Early activists sought protection for children and punishment for abusers. As the child protection movement evolved, new mechanisms emerged to support this work including: the first juvenile court, in Illinois, in 1899; a federal oversight agency - The Children's Bureau - which still exists today; and the Social Security Act in 1930, which provided the first national directive and funding for child welfare services. Each of these events was critical in the development of the nation's child protection system. Nonetheless, much of our modern system has emerged over the last 37 years, beginning in 1962, when Dr. C. Henry Kempe identified the "battered child syndrome." His work resulted in the first broad public awareness of child abuse and neglect. Since then, both state and federal governments have been proactive in their response creating new legislation to direct child protection efforts. Throughout this period we have seen dramatic increases in the number of children and families served, the array of services, and the scope of legal requirements guiding the system. The key components in our current system are highlighted in the following table.   TABLE 1: Key Features of the Child Protection System Federal Legislative Framework Child Abuse Prevention &Treatment Act of 1974 The Indian Child Welfare Act of 1978 Adoption Assistance & Child Welfare Act of 1980 The Adoption & Safe Families Act of 1997 Primary Service Mandate Safety for children Secondary Service Goals Permanency for children by strengthening family or seeking alternative permanent families. (e.g., adoption) Well-being of children Service Providers Government agencies providing statutorily mandated services Contracted and community services used to reduce risk & address family problems Support and Authority Used to Assist Victims Child protection worker responsible (through state statute) to monitor families and offer supportive services Supportive & authoritarian roles also carried by community agencies and police/courts, respectively Examples of Services and Tools Used to Respond Child Abuse and Neglect Hotline Joint police & child protective services response including investigation & assessment Shelter, kinship, and foster care placements Treatment services like parenting classes, substance abuse treatment & counseling Case management & referral Temporary & permanent custody of child Court Role Juvenile or Family Courts provide protection (e.g., legal custody) & oversee decision-making of CPS Criminal Courts used in a few extremely serious cases.   Federal statutes that guide child protection agencies While child abuse and neglect laws vary from state to state, they all must comply with the basic requirements established in the following federal statutes: The Child Abuse Prevention and Treatment Act of 1974 (CAPTA). The act required that each state establish a mandatory reporting system for child abuse and neglect. Through a series of revisions, the most recent of which became law in 1996, the act has established detailed criteria for state programs receiving the limited funds available under the act. These include provisions guiding the definition of abuse and neglect in state statutes; requirements for confidentiality for children and families; immunity for individuals who report abuse and neglect; and provisions requiring guardian-ad-litems for children. The Indian Child Welfare Act of 1978 (ICWA). This act establishes the jurisdiction of Indian tribes in child custody cases involving Indian children. The act provides specific procedures for the timely notification of tribes when Indian children come to the attention of child welfare agencies and placement is being considered, so that tribal membership can be determined.. The Adoption Assistance and Child Welfare Act of 1980 (P.L.96-272). This act establishes procedural safeguards for children to try to ensure that they do not linger in foster care. As amended in 1983, the act establishes administrative and judicial case review to try to ensure that the protective and "best interests" needs of children were met. The statute also requires child welfare agencies to make reasonable efforts to prevent placement and provide services to reunify families. The statute also supports agency programs to secure an alternative permanent family when reunification is not possible. The Adoption and Safe Families Act of 1997 (ASFA). This act is broad in its scope, addressing family preservation, child protection, permanency planning, and adoption concerns. Among its key provisions is a focus on child safety as the first priority in child welfare decision-making. It also calls for states to pass legislation detailing specific criteria for timely permanency planning in all cases and expedited termination of parental rights in cases of extreme child abuse and neglect.   Core values of the Child Protection System The principal purpose of a child protection service is to protect children whose parents or caregivers are unable or unwilling to provide for their safety, basic needs, and emotional security.11Within this framework, it is understood that children are not able to protect themselves and that those who act on their behalf must be guided by what is in the child's best interests. The following values hold true: Every child has a right to adequate care, supervision and freedom from maltreatment. Every child should have a safe permanent family. Parents have the primary responsibility and are the primary resource for their children. In most circumstances, the most desirable place for children is in their own safe and caring family. Most parents want to and can be adequate parents. Most parents experiencing difficulty can be helped to be adequate parents. When parents cannot or will not fulfill their protective responsibilities, the community has the right and obligation to intervene. Once the child welfare agency intervenes to protect a child, two key principles guide its work: 1. Safety is always the first consideration in determining how the best interests of a child will be met. 2. The child's wellbeing and need for a more permanent family are also critical considerations. At a casework level, this typically means that when it can be done safely, services must be provided to strengthen the parent's ability to provide a safe and permanent home for the child. Whenever safety cannot be assured while the child is at home, placement outside the home is made and services are geared at strengthening the family so that the child may be returned home. When this cannot be accomplished in a reasonable timeframe, the agency must look quickly to other resources, including relatives and adoptive families, to provide a permanent family for the child. The basis for this approach can be found in both state and federal statutes. At the state level these laws may also provide more specific guidance to caseworkers by outlining timelines for key decisions and criteria for certain agency actions. For example, statutes often prescribe the number of days within which a child abuse investigation must be completed and sometimes detail what contacts or assessments are required in order to complete an investigation. States vary widely with regard to the specificity of their child abuse laws and policies. Advocates seeking to collaborate should become familiar with their state statute, and with related state and local policies. B. How do cases move through a child protective agency? The following chart provides a brief description of the flow of cases through the typical child welfare system.   What happens during CPS intake and screening? To best describe how the child protection system operates, let's return to the report filed regarding Gina and her children. Before a visit was made to her home, the child protection agency "screened" the report made by the neighbor to determine how it should be handled. Often this means answering only a few simple questions. First, if the allegation were true as reported, would it constitute abuse or neglect according to the state law? Second, is the report credible? In Gina's case the intake worker "screened in" or accepted the report, believing that it was reliable and that Gina's children may be at risk. Had the worker found otherwise, the report would be "screened-out." At that point, it would typically be closed or referred to another agency for assistance.   What happens during an investigation or assessment? Once a case is screened in, the child protection caseworker begins an assessment of the situation. This assessment or investigation typically begins with an interview of the parents and children that is usually conducted in the family home. During this interview, the worker tries to determine what has happened, and whether or not the children are at immediate risk. [See Appendix A for a more a detailed description of the CPS investigation and assessment process.] After receiving the hotline report, a child protection caseworker met with Gina and her children to begin an assessment. The worker learned that Sammy and Jessie are Gina's only children and that Sammy's father is Gina's ex-husband, who does not live in the area. Gina talked freely about the current incident and said she yelled at Sammy to leave the kitchen so he wouldn't get hurt. Although Sammy was not hurt this time when Mark dropped him, he and Jessie are afraid of Mark. Mark has never hit them, but Gina is afraid that if she leaves Mark alone with them he might. Gina also told the worker that the one time Mark came home really drunk, she and the kids stayed at a friend's house overnight. Gina also reported that Sammy and Jessie sometimes had difficulty sleeping after an episode of abuse and that she is really worried about them. A separate interview with Sammy corroborated their mother's account of the incident. The children also stated that they were afraid of Mark and that they worried about their mother. Sammy is upset because his Mother yelled at him to leave the kitchen that night and he didn't know what to do. He went into Jessie's room to try to get her to stop crying. When Mark is in a "bad mood," Sammy says, his mother tells him to stay in his room. The interview with Mark was very brief. Mark admitted to having a "few too many" but dismissed the rest of the allegations as just the "fantasy world of a busybody neighbor." In instances like Gina's, the caseworker will also talk with the neighbor to confirm her report and might contact the police to gather information about their history of calls to the home. In addition, the caseworker might contact a daycare center, school, or pediatrician for additional information about the family. Based on this information, it is the caseworker's responsibility to make several determinations. Is there reason to believe that the allegations of child abuse or neglect are true? State law sets the legal standard against which this is measured. Typically, evidence does not have to "be clear and convincing" but there must be "reasonable cause to believe" that allegations are true. The answer to this question determines whether a case is substantiated (also called "founded"). What, if any, risk of harm to the children currently exists and what is the likelihood that they will be at risk in the future? This assessment of current safety and future risk usually helps a worker to determine what, if any, services will be provided to the family. Cases where the risk is believed to be minimal are usually closed, unless the agency and family agree to services on a voluntary basis.Low to moderate risk cases may receive in-home services designed to support the family, improve parenting, and ultimately lower the risk of future abuse and neglect. Higher risk cases often result in either intense monitoring through in-home services or in the removal of the child from the family to achieve safety. The worker decides to substantiate a finding against Mark because of the risk created when he gets drunk and violent. The caseworker believes that Gina has not intentionally harmed her children and that she has made efforts to protect them. The worker is concerned about Mark's ongoing violence against Gina and its effects on the children. The worker has agreed not to remove the children on the condition that Mark remains out of the home. At this point the caseworker opens a case for in-home services and begins a more in-depth assessment of the family's service needs. What happens during the assessment and service planning phase? Once an initial investigation or assessment is completed, the child protection worker is responsible for continuing to gather information about the family and to determine what services are needed. As the worker spends more time with Gina, he finds out the following: Gina moved to this community two years ago. She and Mark began dating right after she moved. At first, he was very kind to her and to Sammy, helping her get settled and taking Sammy to ball games. He convinced Gina they would "be a family" if she let him move in. As soon as she became pregnant, things got bad. Mark starting drinking more and he would fly into rages, destroying property and attacking Gina. She wanted to ask him to leave, but she quit her job when she became pregnant with Jessie and now relied on Mark for financial support. Mark's parents have also been supportive, and she's worried that if she asks him to leave, she'll lose contact with them. The worker is now also convinced that Gina is severely depressed and may have an alcohol problem. The worker tells Gina she must get a protective order to assure that Mark can not legally come back to the apartment and that she must get an alcohol and psychological evaluation. At this point the worker has begun the process of planning services. The service plan will later be written down and signed and will outline the types of resources clients must access and the requirements they must address. What is the role of the legal system in child protection? Juvenile and Family Court Proceedings The caseworker drops by Gina's home to see how she and the kids are doing. Gina, obviously drunk, answers the door. The worker can see that the apartment is in disarray and can hear Jessie crying. She asks to see the children. Gina tells her to go away and to leave her family alone. As the worker heads back to her car to call for help, she sees Mark standing in the back yard. Gina will no longer talk to the caseworker, so the caseworker decides that the children must be removed from their home in order to be safe. She begins the paperwork to get a court order giving the CPS agency the authority to take Sammy and Jessie out of their home and place them in foster care. During the initial hearing, however, the judge decides to place Jessie and Sammy with Gina, on the conditions that she comply with the recommendations of the substance abuse evaluation and treatment program and that Mark move out and also attend a substance abuse and batterer intervention program. Nationwide, only about 15% of children in substantiated abuse and neglect cases are removed from their homes.As a result, the court is not involved with most children who come to the attention of the child protection agency. Nonetheless, the court plays a critical role in certain circumstances. First, court intervention is needed when an investigation and assessment indicate that a child cannot remain at home safely. In these instances, the court's authority is required to take legal custody of the child so that placement and other services may be provided to protect the child. In certain limited circumstances, the child protection agency may place a child out of the home voluntarily with permission of the parent. Policies governing voluntary placements vary across jurisdictions, but even these placements are subject to juvenile court review after six months. In many jurisdictions, the court may also be involved and allow the children to remain at home with the parent. In these cases the court may oversee the safety of the child and the parents' compliance with the case plan agreement either through an order of supervision or by taking legal custody of the child. When court intervention is needed, federal and state statutes guide the court in overseeing the protection of children.These oversight responsibilities include assuring that: the child protection agency has made reasonable efforts to prevent the removal of the child from the home; there is a sufficient basis for state intervention on behalf of the child; the child is adequately represented; each parent has received adequate due process including notice; representation; and the right to be heard, present evidence, remain silent and appeal; a proper case plan has been prepared for each parent; the child protection agency has either made reasonable efforts to reunite the child with the family once placement has occurred, and/or the agency has documented that reasonable efforts are not warranted because reunification would be detrimental to the safety of the child; each case is reviewed regularly by the court to ensure that the child's need for a permanent family is addressed in a timely manner; and the child protection agency has made efforts to find a permanent home when the child cannot be returned home. The courts also play an integral role in decision-making in child protection. Key steps in the court process include: The Petition. In most states, child protection workers cannot, on their own authority, remove children from their home. They must rely on the authority of either the police or the courts (or in a few cases medical personnel). Even when a child is removed without a court order, the child protection agency is required to file a petition with the court based on timelines established in state law (typically 72 hours or less following removal). The petition contains facts about the alleged abuse or neglect and provides the basis for juvenile court involvement. The Initial Hearing. This is a critical point in the child protection process. During this hearing the court will decide whether or not the allegations in the petition support the need to remove the child or continue a temporary custody order to protect the child. It is also at this hearing that the court ensures that parents have an attorney to advocate for their rights in the process and that a guardian ad-litem (or alternatively a Court Appointed Special Advocate - a CASA) is appointed to ensure that the child's best interests are addressed. Adjudicatory Hearings. These are held to determine whether or not the petition is true - i.e., the child has been abused and neglected - and whether the child should be declared dependent - i.e., whether custody or supervisory authority should be removed from the parent and transferred to the court or the child protection agency. Dispositional Hearings. These are held so that the court may decide what action should be taken after the child is declared dependent. Choices may include returning the child home with supervision from the child protection agency, out-of-home care, and orders for service to the parents and children. Review Hearings. Following the dispositional hearing, the court typically sets a date(s) to review the status of the case, including the case plan, the parents' progress in meeting the requirements of the case plan, and recommendations for changes in the case plan, the child's placement or custody. Permanency Hearings. These are held so that the court may establish a permanent plan for the child. This hearing also considers information documenting the current status of the case in determining how and when the child's need for a safe and permanent family will be met. New requirements established in the Adoption and Safe Families Act of 1997 require that a permanency hearing be held within 12 months of a child's entry into care (and at 15 months for children already in care). This requirement puts an enormous burden on battered women to make quick and effective safety plans for themselves or else run the risk of losing their children permanently. Once the court is involved, the number of people involved in the case can increase dramatically. In addition to family members, the child protection caseworker, service providers, and the judge, legal counsel represents each of the parties to the case. This means that one or more attorneys will represent the parents. The child protection agency will also be represented. Finally, the court will assign a guardian-ad-litem (an attorney) and/or a court appointed special advocate for the child. With these participants, and through this process, the case plan, services to family members, and, ultimately, the outcome of the case are decided. Law Enforcement Law enforcement plays an integral role in the protection of children from child abuse and neglect. In nearly all jurisdictions, police share responsibility with the child protection agency to receive and respond to reports of child maltreatment. In so doing, they carry two primary roles. First, they are responsible for the immediate protection of the child - particularly in cases where there is an imminent risk of harm. In many cases, this includes the authority to take protective custody of the child to ensure safety. Second, police are obligated to investigate child abuse and neglect when a crime may have been committed. In many jurisdictions, these investigations only occur when children have been killed or seriously injured as a result of abuse or neglect, when there is sexual abuse of a child, or when there is evidence of other criminal activity by the parent or caretaker. An additional role for law enforcement is the safety of service providers. In many jurisdictions, police provide protection for caseworkers when they are entering a potentially dangerous situation. Each of these responsibilities is carried out in coordination with the child protection agency. While many jurisdictions operate informally, in some states, statute or policy requires formal agreements between child welfare and police. Cross reporting of cases between the police and child protection may be mandated to ensure that cases are appropriately investigated and services provided. Jurisdictions may also establish protocols for joint investigations to ensure that the work of the two agencies is coordinated, to minimize the trauma of multiple interviews for children, and to ensure that juvenile and criminal court actions are coordinated. Several communities across the country have already built collaborations that address domestic violence and child maltreatment collaboratively. Among these are:   The AWAKE Program. Located at Children's Hospital in Boston, Massachusetts, this strengths-based and family-centered program was one of the first to make the link between domestic violence and child protection. Offering counseling, support groups, and advocacy to battered women with abused and neglected children, the program successfully promotes safety for mothers and children. In 16-month follow-up with a group of 46 mothers served by advocates, 85% of the women reported they were free from violence, and in only one family had children been placed in foster care.   Massachusetts Department of Social Services. This practice integration model has brought domestic violence expertise to traditional child protective services through a statewide program in which domestic violence specialists work hand-in-hand with child protection caseworkers. The specialists provide case consultation, direct advocacy, and linkages to community resources for battered women and children served by the child welfare agency. Policy guidance supports decision-making that is responsive to the concerns of battered women beginning with screening and investigation and including risk assessment, family assessment, case planning and service delivery.   Michigan's Families First Domestic Violence Collaboration Project. This cross-system collaboration between shelter programs and family preservation programs is offered in eleven communities across the state. The program provides intensive services designed to keep children safe and with their mothers. The program has also provided models for cross-training that integrate principles from family-centered practice, child protection, and domestic violence. These three pioneering programs are among a growing array of models that are serving battered women and their abused and neglected children (see Appendix B for suggestions about building positive collaborations). In Jacksonville, Florida, and Cedar Rapids, Iowa, child protection and domestic violence programs are working together in community partnership models. In San Diego and Minneapolis, hospital-based programs are in place, and partnerships among police, hospitals, and child protection are developing. In Hawaii, Healthy Start programs are combining early intervention for children with screening and intervention in domestic violence. [For more examples, see Family Violence: Emerging Programs for Battered Mothers and their Children, published in 1998 in Reno, Nevada, by the National Council of Juvenile and Family Court Judges.] B. What Would a Collaborative Response Look Like? The following scenario provides one example of how domestic violence advocates and CPS workers could collaboratively respond to families in which there is domestic violence and risk to the children. This particular example, rather than neatly solving the complex issues in such families, shows a process through which advocates and workers provide ongoing resources to the adult victim, while taking actions necessary to protect the children. When Gina talked with her caseworker about Mark's violence, he told Gina about a collaborative program between the local domestic violence shelter program and CPS. Gina agreed to participate, and the worker called the shelter to let them know that Gina would call that afternoon. When Gina called, an advocate talked with her to get a basic understanding of her situation and needs and then set up a time to meet with Gina the next day. Gina told the advocate that she believes Mark could be a good partner and father to Sammy if he didn't drink. She also admitted that she probably drinks too much and just doesn't seem to have "any energy anymore." The advocate talked with Gina about Sammy and Jessie. She validated Gina's efforts to keep them out of the way, but also tried to make sure that Gina understood how the drinking and the abuse affect them and what actions CPS must take if the kids are in danger. They talked about what Gina thinks will keep her and the kids safe. After getting Gina's permission to talk to the worker, the advocate called the worker, and they developed a plan to propose to Gina and to Mark. The proposed plan called for the following: Mark would move out of the apartment, go to a substance abuse/batterer intervention program sponsored by CPS, pay child support, and visit with Jessie while his parents supervised. Gina would attend counseling to address her substance abuse and depression and would bring Sammy to a children's group run by the shelter. After 6 months, CPS would reevaluate the potential danger to Sammy and Jessie. Both parents agreed to this plan. After six weeks of attending classes, Mark stopped going. He also told Gina he wasn't going to pay child support for a child he only sees once a week. Desperate for money and tired of single parenting, Gina invited Mark to move back in. The CPS worker was notified about Mark's lack of attendance. The worker called the domestic violence advocate to let her know, and went out to check on Sammy and Jessie. The advocate also contacted Gina to see how she might help. C. Principles for Domestic Violence-Child Protection Collaboration Successful collaboration requires a shared framework for the response to battered women and their children. Core principles already guide collaborative efforts in communities across the country. The following discussion explains each principleand raises key policy challenges that face advocates and child protection workers as they practice together to keep children and their battered mothers safe. Principle 1:    The safety of children is the priority. Every procedure, policy or practice of an integrated response to child maltreatment and domestic violence must ensure that children are protected. For example, services to support a battered mother's safety and autonomy must not compromise safety for children. Commitment to this principle can provide essential common ground as child protection workers and domestic violence advocates work through the complex issues of building a collaborative response. Policy challenges raised by Principle 1: Does a child's witnessing domestic violence constitute abuse/neglect? There is growing consensus that witnessing domestic violence is harmful to children. However, the harm will not be the same for every child, because the level of violence and each child's experience of the violence are different. Therefore, there is much less agreement about when the harm from witnessing domestic violence is serious enough by itself to constitute possible child abuse and neglect that should be reported to authorities. While it is clear that situations in which children are physically injured or sexually assaulted during a domestic violence incident should be reported, other situations are less straightforward and require a careful assessment of danger and risk. For most child protection agencies, the threshold for the finding of emotional abuse and even neglect is quite high, and many domestic violence cases, therefore, will be inappropriate for a referral to CPS. Typically, CPS intervention requires independent corroboration that documents that the neglect and emotional harm is significant and is caused by the actions of the parent. When domestic violence cases fall below the threshold for child protection intervention, community-based services are needed to address the problems that children may experience.   Principle 2: Child safety can often be improved by helping the mother to become safe and by supporting the mother's efforts to achieve safety. Child protection strategies should include efforts to enhance a battered mother's safety. Policy challenges raised by Principle 2: Should CPS routinely assess for domestic violence at intake? Among many child protection workers and domestic violence advocates there is a great deal of concern about whether or not routine child protection service intake assessment for domestic violence should be done. Child protection agencies fear that this assessment will overwhelm the agency with even more new cases. Domestic violence advocates fear that child protection may fail to address, or, even worse, compromise the mother's safety during the intake process. In reality, assessing for domestic violence is already a part of the investigation and risk assessment procedures for many child protection agencies. There is growing consensus that child protection should develop the skills and protocols needed to effectively assess for domestic violence, to determine which cases require child protection intervention and which should be referred to community agencies, and to offer services that promote safety for mother and child.   How do we resolve confidentiality issues in child protection? Privacy and confidentiality are cornerstones of domestic violence advocacy with battered women. In contrast, child protection agencies are often bound by policies that mean that information contained in safety plans, service plans and case records may be accessible to perpetrators. A batterer may use this information in custody proceedings or to thwart safety plans developed to protect a woman and her children. Confidentiality issues and misunderstandings often hinder collaboration. To avoid unnecessary conflict, advocates and CPS should work together to understand existing policy and look for ways to improve it. Confidentiality policies must balance the CPS's need for information with the battered mother's right to privacy and with advocates' legal/ethical requirements to keep certain information confidential.   Principle 3: Safety for battered mothers and their children can be supported by holding the batterer, not the adult victim, accountable for the domestic abuse.   By focusing on perpetrator accountability, we open a new range of resources that can protect children - including restraining orders, prosecution of domestic assaults, and batterer intervention programs. By focusing on perpetrator accountability, we are less likely to blame one victim for harm to another. Batterers must be held accountable for their abuse of women and children, and they must have access to services that eliminate violence and that appropriately and safely support their role as parents. While most would agree with this principle, in practice the issues become more complicated. Gina, for example, did not hit Sammy or Jessie, nor was she the one who dropped Sammy. In fact, Gina tried to get Sammy to leave the kitchen and get out of Mark's way. However, Gina is also a parent who is responsible for making decisions about her kids' lives. When Gina decided that Mark could move back in, after he dropped out of the substance abuse/batterer intervention program, she made a decision that could place her kids at risk. Her decision to let Mark move back in was based on her need for financial support. It is important to understand that Gina did not decide, "Yes, I want Mark to move back in so that Sammy and Jessie are at risk," but, rather, "I have to let him back in or else we'll be homeless." Given Gina and her children's need for financial support, she had little other choice but to let him move back in. The key to keeping Gina safe is to look beyond the decision she made to fully understand why that was her decision. As CPS and other agencies make efforts to help Gina and her children meet their financial needs, Gina's responsibility is to accept and work with those who are trying to help her. (In Gina's case, financial independence through employment may take awhile, and she may need temporary support from the government along with opportunities to address her substance abuse and depression.) At the same time, Mark needs to be mandated back to substance abuse treatment and batterer intervention programs. If Mark is once again living with the children and, as a result, the children are in danger, child protection and the courts may have no choice but to remove them from Gina's care. Understanding the basis for battered mothers' decision-making about their lives and the lives of their children will provide the information necessary to effectively safety plan with them. Understanding a battered mother's decision-making also points out that strategies to protect children that hold mothers like Gina liable for "failure to protect" - either in juvenile or criminal courts - will be counterproductive. For example, arresting Gina for getting access to Mark's financial support would not make Jessie or Sammy safe, nor would it change her decision, as she believed she had no other choice. Such strategies will actually decrease a woman's options (thereby increasing her danger and her partner's control) and may subject children to unnecessarily being taken from their homes and families. Policy challenges raised by Principle 3: Decision-making in Child Protection A decision to substantiate or confirm a report of abuse and neglect is typically made in the context of several key questions: (1) Did the reported incident occur? (2) Is the child at continued risk of harm? (3) Who is responsible for the maltreatment? and (4) Who can protect the child? The last two questions pose some unique challenges in cases involving domestic violence. How do we minimize allegations of failure to protect? When child protection workers substantiate maltreatment, they must typically identify what type of abuse occurred (e.g., physical abuse, neglect, sexual abuse, or emotional maltreatment) and how the parent   Abuse and Women with Disabilities Margaret A. Nosek and Carol A. Howland Defining Disability and Abuse For the purpose of this paper, the term disability will encompass the following impairments: disability that can increase vulnerability to abuse may result from physical, sensory, or mental impairments, or a combination of impairments; physical disability resulting from injury (e.g., spinal cord injury, amputation), chronic disease (e.g., multiple sclerosis, rheumatoid arthritis), or congenital conditions (e.g., cerebral palsy, muscular dystrophy); sensory impairments consisting of hearing or visual impairments; and mental impairments comprising developmental conditions (e.g., mental retardation), cognitive impairment (e.g., traumatic brain injury), or mental illness. Emotional abuse is being threatened, terrorized, severely rejected, isolated, ignored, or verbally attacked. Physical abuse is any form of violence against one's body, such as being hit, kicked, restrained, or deprived of food or water. Sexual abuse is being forced, threatened, or deceived into sexual activities ranging from looking or touching to intercourse or rape. Prevalence of Violence Against Women with Disabilities The prevalence of abuse among women in general has been fairly well documented, yet only a few North American studies (review by Sobsey, Wells, Lucardie, & Mansell, 1995), primarily from Canada, have examined the prevalence among women with disabilities. The DisAbled Women's Network of Canada (Ridington, 1989) surveyed 245 women with disabilities and found that 40% had experienced abuse; 12% had been raped. Perpetrators of the abuse were primarily spouses and ex-spouses (37%) and strangers (28%), followed by parents (15%), service providers (10%), and dates (7%). Less than half these experiences were reported, due mostly to fear and dependency. Ten percent of the women had used shelters or other services, 15% reported that no services were available or they were unsuccessful in their attempts to obtain services, and 55% had not tried to get services. Sobsey and Doe (1991) conducted a study of 166 abuse cases handled by the University of Alberta's Sexual Abuse and Disability Project. The sample was 82% women and 70% persons with intellectual impairments, and covered a very wide age range (18 months to 57 years). In 96% of the cases, the perpetrator was known to the victim; 44% of the perpetrators were service providers. Seventy-nine percent of the individuals were victimized more than once. Treatment services were either inadequate or not offered in 73% of the cases. The Ontario Ministry of Community and Social Services (Toronto Star, April 1, 1987) surveyed 62 women and found that more of the women with disabilities had been battered as adults compared to the women without disabilities (33% versus 22%), but fewer had been sexually assaulted as adults (23% versus 31%). An extensive assessment of the sexuality of noninstitutionalized women with disabilities, which included comprehensive assessment of emotional, physical, and sexual abuse, was conducted by the Center for Research on Women with Disabilities (CROWD) through a grant from the U.S. National Institutes of Health. This study also covered other areas that may be associated with abuse, such as sexual functioning, reproductive health care, dating, marriage, parenting issues, and the woman's sense of self as a sexual person. The design of the study consisted of (1) qualitative interviews with 31 women with disabilities, and (2) a national survey of 946 women, 504 of whom had physical disabilities and 442 who did not have disabilities. Disabilities reported most frequently included spinal cord injury, cerebral palsy, muscular dystrophy, multiple sclerosis, and joint and connective tissue diseases. Abuse issues emerged as a major theme among the 31 women interviewed in the first phase of this study. An analysis of reports of abuse in those interviews was described by Nosek (1996). Twenty-five of the 31 women reported being abused in some way. Of 55 separate abusive experiences, 15 were reported as sexual abuse, 17 were physical (nonsexual) abuse, and 23 were emotional abuse. The findings from the qualitative study were used to develop items for the national survey. Two pages of the 51-page survey were devoted to abuse issues, encompassing more than 80 variables, including type of abuse by perpetrator and age when abuse began and ended, plus two open-ended questions. Analyses of these data (Young, Nosek, Howland, Chanpong, & Rintala, 1997) have revealed that abuse prevalence (including emotional, physical and sexual abuse) was the same (62%) for women with and without disabilities. There were no significant differences between percentages of women with and without disabilities who reported experiencing emotional abuse (52% versus 48%), physical abuse (36% in both groups), or sexual abuse (40% versus 37%). The most common perpetrators of emotional and physical abuse for both groups were husbands, followed by mothers, then fathers. Emotional abuse by husbands was reported by 26% of all women in both groups; physical abuse by husbands was reported by 17% of all women with disabilities and 19% of all women without disabilities. The most common perpetrator of sexual abuse was a stranger, as reported by 11% of women with disabilities and 12% of women without disabilities. Women with disabilities were significantly more likely to experience emotional and sexual abuse by attendants and health care workers. Women with disabilities reported significantly longer durations of physical or sexual abuse compared to women without disabilities (3.9 years versus 2.5 years). In an analysis of sexual functioning, abuse was found to be a significant predictor of lower levels of satisfaction with sex life among women with disabilities (Nosek, Rintala, Young, Howland, Foley, Rossi, & Chanpong, 1995) Others have reported a history of sexual abuse among 25% of adolescent girls with mental retardation (Chamberlain, Rauh, Passer, McGrath, & Burket, 1984), 31% of those with congenital physical disabilities (Brown, 1988), 36% of multihandicapped children admitted to a psychiatric hospital (Ammerman, Van Hasselt, Hersen, McGonigle, & Lubetsky, 1989), and 50% of women blind from birth (Welbourne, Lipschitz, Selvin, & Green, 1983). In spite of these high percentages, few women receive treatment from victim services specialists (Andrews & Veronen, 1993). Abuse Interventions for Women with Disabilities There have been virtually no studies that examine the existence, feasibility, or effectiveness of abuse interventions for women with disabilities. In both the disability rights movement and the battered women's movement, it is generally acknowledged that programs to assist abused women are often architecturally inaccessible, lack interpreter services for deaf women, and are not able to accommodate women who need assistance with daily self-care or medications (Nosek, M.A., Howland, C.A., & Young, M.E. 1998). Merkin and Smith (1995), in discussing the needs of deaf women, state that counseling is more effective when sensitive to deaf culture issues and appropriate communication techniques. Crisis interventions typically include escaping temporarily to a woman's shelter, having an escape plan ready in the event of imminent violence if the woman chooses to remain with the perpetrator, and escaping permanently from the abuser. These options may be problematic for the woman with a disability if the shelter is inaccessible or unable to meet her needs for personal assistance with activities of daily living, if the shelter staff are unable to communicate with a deaf or speech-impaired woman, if she depends primarily on the abuser for assistance with personal needs and has no family or friends to stay with, or if she is physically incapable of executing the tasks necessary to implement an escape plan such as packing necessities, hiding money, and driving or arranging transportation to a shelter or friend's home. Andrews and Veronen (1993) list four requirements for effective victim services for women with disabilities. First, service providers need to provide adequate assessment of survivors, including questions about disability-related issues. Second, abuse service providers should be trained to recognize and effectively respond to needs related to the disability, and disability service providers should be trained in recognizing and responding to physical and sexual trauma. Third, barriers to services should be eliminated by providing barrier-free information and referral services, by ensuring physical accessibility to facilities, by providing 24-hour access to transportation, to interpreters, and to communication assistance, and by providing trained personnel to monitor risks and respond to victims receiving services through disability programs. Finally, persons with disabilities who are dependent on caregivers, either at home or in institutions, may need special legal protection against abuse. The National Domestic Violence Hotline keeps a database of battered women's shelters throughout the country, with indications of their architectural accessibility and the availability of interpreter services. Although the hotline is equipped with telecommunication devices for persons who are deaf, it is rarely used. The National Coalition Against Domestic Violence has issued a manual that gives specific guidelines for battered women's programs on implementing accessibility modifications according to the requirements of the Americans with Disabilities Act and increasing sensitivity and responsiveness among program staff to the needs of abused women with disabilities (National Coalition Against Domestic Violence, 1996). Critique of Studies on Abuse and Disability Until recently, the problem of abuse among people with disabilities has received very little attention. Early studies suffered from many methodological weaknesses. Essential constructs and variables important to statistical analysis were rarely defined. There was a particular lack of distinction among emotional, physical, and sexual abuse. The studies used unstandardized measurement instruments and techniques. Global references were made to the type of abuse, for example, emotional versus sexual; however, there was little attempt to document or categorize specific incidents by perpetrator. Samples in these studies were generally quite heterogeneous in terms of disability type, gender, and age. There was also the use of convenience sampling, such as using clients of intervention programs or police reports, as opposed to representative or random sampling. Statistical analyses rarely go beyond frequencies and measures of central tendency. Due to the heterogeneity of the samples, analyzing specific experiences of individuals with specific characteristics (such as sexual abuse among adult women with mental illness) would result in subsamples too small to allow the use of more sophisticated analytic procedures. The recent study by the Center for Research on Women with Disabilities addressed a number of these issues. It had clearly defined variables; assessed types of abuse, perpetrator, and duration of abuse; sampled a broad range of women nationwide, including an able-bodied comparison group; and was restricted to a defined sample of adult women with physical disability. The issue of designing and implementing appropriate intervention studies for women with disabilities has received no attention beyond observation and speculation. Conclusion There is no question that abuse of women with disabilities is a problem of epidemic proportions that is only beginning to attract the attention of researchers, service providers, and funding agencies. The gaps in the literature are enormous. For each disability type, different dynamics of abuse come into play. For women with physical disabilities, limitations in physically escaping violent situations are in sharp contrast to women with hearing impairments, who may be able to escape but face communication barriers in most settings designed to help battered women. Certain commonalities exist across disability groups, such as economic dependence, social isolation, and the whittling away of self-esteem on the basis of disability as a precursor to abuse. Research that employs methodologic rigor must be conducted with women who have disabilities such as blindness, deafness, mental illness, and mental retardation. Particular attention must be paid to identifying vulnerability factors that are disability-related as opposed to those factors experienced by all women. We must know more about interventions that are effective for women with disabilities. Considerable work has been done in this area for women in general; however, many of the recommended strategies are not feasible for women with disabilities. Few of the strategies listed in classic safety plans are possible for women who must depend on their abuser to get them out of bed in the morning, dress them, and feed them. There are only a handful of programs across the country that specifically address the needs of abused women with disabilities, making controlled intervention studies very difficult. Much more work must be done to increase the awareness of providers of disability-related services so that they can recognize abuse among their clients and make appropriate referrals to battered women's programs. Correspondingly, much more work must be done to increase the capacity of battered women's programs to serve women with all types of disabilities. Authors of this document: Margaret A. Nosek, Ph.D. Carol A. Howland, M.P.H. February 1998 Nosek, M. & Howland, C. (1998, February). Abuse and Women with Disabilities.. Harrisburg, PA: VAWnet, a project of the National Resource Center on Domestic Violence/Pennsylvania Coalition Against Domestic Violence. Retrieved 10/4/09   References Ammerman, R. T., Van Hasselt, V. B., Hersen, M., McGonigle, J. J., & Lubetsky, M. J. (1989). Abuse and neglect in psychiatrically hospitalized multihandicapped children. Child Abuse & Neglect, 13, 335-343. Andrews, A. B., & Veronen, L. J. (1993). Sexual assault and people with disabilities. Special issue: Sexuality and disabilities: A guide for human service practitioners. Journal of Social Work and Human Sexuality, 8(2), 137-159. Asch, A., & Fine, M. (1988). Introduction: Beyond Pedestals. In: Fine, M., & Asch, A. (Eds.) Women with disabilities: Essays in psychology, culture, and politics. Philadelphia, PA: Temple University Press. Brown, D. E. (1988). Factors affecting psychosexual development of adults with congenital physical disabilities. Physical and Occupational Therapy in Pediatrics, 8(2-3), 43-58. Chamberlain, A., Rauh, J., Passer, A., McGrath, M., & Burket, R. (1984). Issues in fertility control for mentally retarded female adolescents I: Sexual activity, sexual abuse, and contraception. Pediatrics, 73, 445-450. Merkin, L., & Smith, M. J. (1995). A community based model providing services for deaf and deaf-blind victims of sexual assault and domestic violence. Sexuality and Disability, 13(2), 97-106. National Coalition Against Domestic Violence. (1996). Open minds, open doors: Technical assistance manual assisting domestic violence service providers to become physically and attitudinally accessible to women with disabilities. Denver, CO: National Coalition Against Domestic Violence. Nosek, M.A. (1996). Sexual abuse of women with physical disabilities. In D. M. Krotoski, M. A. Nosek, & M. A. Turk (Eds.), Women with physical disabilities: Achieving and maintaining health and well-being. (pp. 153-173). Baltimore, MD: Paul H. Brookes. Nosek, M.A. (1996). Wellness among women with physical disabilities. In D. M. Krotoski, M. A. Nosek, & M. A. Turk (Eds.), Women with physical disabilities: Achieving and maintaining health and well-being. (pp. 17-33). Baltimore, MD: Paul H. Brookes. Nosek, M.A., Howland, C.A., & Young, M.E. (1998). Abuse of Women with Disabilities: Policy Implications. Journal of Disability Policy Studies 8 (1,2), 158-175. Nosek, M.A., Rintala, D.H., Young, M.E., Howland, C.A., Foley, C.C., Rossi, C.D., & Chanpong, G. (1995). Sexual functioning among women with physical disabilities. Archives of Physical Medicine and Rehabilitation, 77, (2), 107-115. Ontario Ministry of Community and Social Services. (1987). Disabled women more likely to be battered, survey suggests. The Toronto Star, April 1, F9 Ridington, J. (1989). Beating the "odds": Violence and women with disabilities (Position Paper 2). Vancouver: DisAbled Women's Network: Canada. Sobsey, D., Wells, D., Lucardie, R., & Mansell, S. (Eds.) (1995). Violence and disability: An annotated bibliography. Baltimore, MD: Paul H. Brookes. Sobsey, D., & Doe, T. (1991). Patterns of sexual abuse and assault. Sexuality and Disability, 9(3), 243-260. Welbourne, A., Lipschitz, S., Selvin, H., & Green, R. (1983). A comparison of the sexual learning experiences of visually impaired and sighted women. Journal of Visual Impairment and Blindness, 77, 256-259. Young, M.E., Nosek, M.A., Howland, C.A., Chanpong, G., Rintala, D.H: (1997) Prevalence of abuse of women with physical disabilities. Archives of Physical Medicine and Rehabilitation Special Issue. 78 (12, Suppl. 5) S34-S38 Battered Women’s Protective Strategies By Sherry Hamby With contributions from Andrea Bible When exploring battered women's protective strategies, the first question to ask is, “Protection from what?” Protection from further violence is a natural and obvious answer to this question, but it is not the only answer. Many other domains of a woman's life are also threatened by battering: her financial stability, the well-being and safety of her children, her social status and the degree to which she is subjected to a stigmatized identity, her psychological health and sense of self-worth, and her hopes and dreams for the course of her life. These are just a few of the areas that are routinely threatened by a woman's abusive partner. Indeed, the threats to these domains may in some cases be greater than the threats of injury or physical pain. Victims are never responsible for the battering perpetrated against them, but, just as people cope and respond to other negative events, victims must also cope and respond to battering. Few people recognize that women are often attempting to cope with numerous threats posed by battering, not just the threat of bodily harm. Unfortunately, it is not always possible to protect oneself from all of these harms simultaneously, or even to spread the risks more or less equally across these domains. Rather, acts that protect against one form of harm often exacerbate other harms. In particular, the unintended consequences of leaving for battered women and their children, especially leaving abruptly in an emergency context, are under-acknowledged by many scholars and advocates (Davies, 2009). It is perhaps natural to assume that escaping violence as quickly as possible is an obvious choice for any victim. The reality, however, can be much bleaker. Some women are so destitute, both financially and socially, that leaving, especially in a short time frame, may be worse than staying. According to Hamby and Gray-Little (2007): The dangers of staying with a violent partner may be less than the dangers of living on the streets. The pain of an occasional beating may be less than the pain of losing custody of one's children to a violent parent (p. 28-5). Many in the general public, and even advocates and scholars with extensive experience in the field of partner violence, may find it difficult to accept that conditions of poverty and social isolation exist for so many women. Nonetheless, assumptions that leaving is always better or safer than staying have meant that people do not always recognize the wide array of protective strategies that victims use. There are many strategies in addition to leaving the abuser or staying in a shelter. One goal of this review is to broaden the definitions of both what women are trying to protect and how they are trying to protect it. Although many of these protective strategies are already known to advocates and have been previously documented in the research, there is still a disconnect between women's lived realities in comparison with both the public stereotypes about battered women and the types of services offered to support them. It is hoped that this document will be a step towards expanding both perceptions and services. A Holistic Approach “…battered women are the strongest women. And nobody will ever change my mind with that. We've had to learn to how to survive” (Melinda, quoted in Davis, 2002, p. 1254). To fully understand battered women's experiences, a holistic perspective is required. This perspective expands the meaning of “protective strategies,” and raises awareness of the many obstacles that victims confront. Although it is true that there are many more services and legal protections available to victims today than there were 30 or 40 years ago, it is still equally true that most women face substantial constraints in accessing services or using other protective strategies (Davies, Lyon, & Monti-Catania, 1998; Justice & Courage Oversight Panel, 2008). Hamby (2008) organized these constraints into five categories: batterer's behavior, financial obstacles, institutional obstacles, social obstacles, and personal values that complicate women's choices. Batterer's attempts to maintain power and control over their victims manifest themselves in many ways, such as threats to kill the victim if she leaves or attempts to make other changes in their relationship (Pence & Paymar, 1993). Contrary to the widespread assumption that leaving is the best way to increase safety, there is ample evidence that much violence is initiated or worsens after separation as the batterer redoubles efforts to maintain control (Mahoney, 1991; Tjaden & Thoennes, 1998, 2000). Not all constraints are due to the batterer, however (Davies et al., 1998; Hamby, 2008). There are financial obstacles, such as insufficient funds to rent an apartment or home, lack of health care for oneself or one's children, or the ability to take time off work to address the effects of the abuse. Financial constraints can limit other coping efforts such as seeking counseling. There are also institutional obstacles, such as limited shelter stays that do not allow sufficient time to set up a new home and job, requirements of multiple court appearances for women who do not have access to childcare or transportation, and the dearth of civil attorneys for low-income women. Many services are primarily organized around helping women leave, and if they do not wish to leave they may find few relevant institutional services (Davies, 2008). There are also social obstacles, such as objections by the victim's or perpetrator's families to divorce or terminate the relationship. Members of some cultural groups or communities may experience pressure not to disclose the violence at all. Further, institutional and social obstacles are often exacerbated for certain groups, including immigrant women, elders, youth, pregnant women, lesbian and bisexual women, gay men, transgender people, people of color, women with disabilities, and other groups who may have special needs, complicated legal issues, or other considerations that are not always addressed by standard services. Finally, personal values, such as beliefs that divorce is wrong, can complicate women's choices as they simultaneously try to remain true to their ideals and protect themselves and their children (Hamby, 2008). The costs of giving up these values can be substantial, both psychologically and socially. For example, if their church or other organization rejects them for breaching its values, a victim might lose considerable social support and even a source of financial and in-kind assistance. Women face dozens of constraints as they strategize about what to do. Protective Strategies: Understanding What We Know and Don't Know To the extent that any data on pro-active, protective behaviors are offered at all, the existing research literature has the most to say on strategies women use to protect themselves and their children against physical violence. The lack of research on other strategies battered women use by no means implies they are less frequent or less important —just less studied. It is important to note, too, that in some cases I have interpreted published data differently than the original authors. Specifically, sometimes behaviors that are interpreted as dysfunctional or passive by the original researchers are considered here to be protective of other goals or needs. For example, choosing not to disclose abuse is often interpreted as denial or some other cognitive distortion. Concealing abuse, or other strategies to dis-identify with victimization, however, can just as easily be seen as impression management strategies that are efforts to minimize the social stigma of being publicly identified as a victim or to minimize the shame that would come to the family for revealing a family secret. Such impression management strategies, or efforts to control others' perceptions of oneself, are common among those with potentially concealable stigmatizing conditions (Goffman, 1963; Herek & Capitanio, 1996). Oftentimes, researchers describe the strategies most clearly connected to leaving and terminating a relationship as the most protective or best coping strategies. Yet, they typically give little consideration to whether the use of these strategies may actually increase physical risk via separation violence rather than protect women against physical harm (Mahoney, 1991). For example, in the National Violence Against Women Survey (NVAWS), 22% of women victimized by a former spouse reported that the violence occurred after the relationship ended. In fact, in 4% of cases the violence only began after the relationship ended. The pattern for stalking was even more dramatic: 43% of stalking victims were stalked only after terminating a relationship (Tjaden & Thoennes, 1998). Leaving is almost always held up as the gold standard of good coping despite considerable evidence that terminating a relationship is not always a successful strategy for ending abuse. Finally, the other major limitation of the research on coping and protective strategies is that it usually focuses only on battered women who go to battered women's shelters. In many cases, these are the women with the fewest resources or who are in the worst circumstances. Many women leave abusive, maltreating partners without ever visiting a shelter, speaking with an anti-domestic violence advocate, or disclosing the violence to a civil or criminal court. We know very little about them or their protective strategies. Nonetheless, and despite the limitations of the research, there is substantial evidence that women engage in all kinds of protective strategies and seek many types of help as they attempt to improve their situations, whether they remain in or leave their relationships. The evidence for several specific strategies is presented below. Specific Protective Strategies Immediate Situational Strategies Although much of the literature focuses on long-term protective strategies, a few studies have looked at protective responses in the immediate context of a physical or sexual assault. The first coping responses often occur during or just after an assault. Leaving the house or escaping the scene of the assault was reported by 19% of women in one study (Magen, Conroy, Hess, Panciera, & Simon, 2001). In a randomly drawn community sample, Hamby and Gray-Little (1997) found that immediate self-protective strategies, such as leaving the situation, getting someone's help, or calling the police, were reported by 20% of women. One nationally representative sample found that 16% ran to another room, 8% left the house, and 6% called someone other than the police (Kaufman Kantor & Straus, 1990). Women also try to avoid potentially violent situations: 63% in a study by Yoshihama (2002). Although some authors consider avoidance a passive, poor coping strategy, women's own ratings showed that avoiding violent situations was often an effective protective strategy. Hitting back is another immediate situational strategy. Although virtually any response can lead to an escalation of the batterer's violence, hitting back may be riskier than most. It may also create legal problems for women, including leading to assault charges against them or damaging their positions in a custody contest. However, some women do choose this strategy: 12% in one nationally representative sample (Kaufman Kantor & Straus, 1990). Although the severity of the violence perpetrated against them and the physical environment can constrain victims' ability to flee or engage in other immediate responses, it is clear that many women respond protectively in the moment that violence occurs. Protecting Children, Family, Friends, and Pets Oftentimes, the welfare of others is foremost on a victim's mind. Victims' specific concerns about others are better documented than the specific strategies used to address these concerns. Sometimes protecting others manifests as immediate situational strategies. For example, in one small study of 17 battered women with children, 65% described removing the children from the scene of the violence by moving away from them or putting them in their bedrooms (Haight, Shim, Linn, & Swinford, 2007). Other steps are longer term. Haight et al. (2007) found that almost half of the sample (47%) spoke of reassuring their children and emphasizing to them that the fighting was not the children's fault. Some mothers, ranging from 16% to 24% in two studies, try to teach their children to make nonviolent choices in their own relationships (Haight et al., 2007; Levendosky, Lynch, & Graham-Bermann, 2000).   The desire to protect others sometimes limits the choice of coping strategies. Across several studies of threats to pets, 26% of women reported that they delayed terminating their relationship because of batterers' threats to kill or harm their companion animals if they left (Hamby, 2008). This is a good example of a situation where no single protective strategy can minimize all risks simultaneously. Although the data available focus on children and pets, it is likely that victims try to protect all loved ones who are threatened. Using “Classic” Legal and Anti-Domestic Violence Services Calling the police. Substantial numbers of women call the police in order to obtain protection from their batterer, especially women who are victims of the most severe battering. As with any single strategy, calling the police may have limited effectiveness in preventing future violence and may create other problems. When victims call the police they may expose the batterer to violence from the police, as well as face retaliatory violence from the batterer or the possibility that they themselves may be arrested (Hirschel & Buzawa, 2002; Martin, 1997; Ritchie, 2006). Law enforcement involvement can also be risky for women who may be worried about involvement from child protective services or immigration enforcement. Studies of women who have had contact with shelters or social services indicate that between 32% and 78% have also called the police (Bui, 2003; Magen et al., 2001; Rounsaville, 1978; Rusbult & Martz, 1995). In the National Crime Victimization Survey, 53% of women reported their intimate partner victimizations to police between 1993 and 1998 (Rennison & Welchans, 2000). In other nationally representative community surveys rates of reporting to the police are lower, most likely because the typical violence reported in such surveys is minor and infrequent. NVAWS found that 21% of female victims contacted the police (Tjaden & Thoennes, 1998). Furthermore, 27% of all victimizations were reported, but not always by the victim (Tjaden & Thoennes, 1998). Although the rates of reporting are lower in community surveys, more severe forms of violence are more likely to be reported to the police. In one survey, Kaufman Kantor and Straus (1990) found that women who sustained severe violence were four times more likely to call the police than women who sustained minor violence (14% vs. 3%). However, not all groups are equally likely to turn to police. For example, using data from Houston, Texas, Bui (2003) estimates that Vietnamese immigrants are five times less likely to call the police than other ethnic groups in Houston. Fears of problems with immigration authorities (whether victims are documented or not) and fears of racial or ethnic discrimination by law enforcement may prevent some victims from contacting police or other authorities (Bui, 2003). Obtaining a restraining order/order of protection. NVAWS found that 17% of victimized women attained a temporary restraining order. Obtaining a protection order is often more common among women who have engaged in other forms of help-seeking (Dutton, Ammar, Orloff, & Terrell, 2007; Strube & Barbour, 1984). However, numerous problems exist regarding restraining orders that may affect their use by victims. In the NVAWS, for example, 51% of the women who obtained orders said their partner violated their restraining order (Tjaden & Thoennes, 1998). In a sample of immigrant women, 37% felt an order of protection would increase their danger (Dutton et al., 2007). Other problems include lack of legal representation in civil protection order hearings for low-income women and limited enforcement of protection orders in some jurisdictions. Further, despite the full faith and credit provisions of the Violence Against Women Act, which should ensure that orders issued by all states and tribal jurisdictions are respected throughout the country, enforcement of protection orders across jurisdictional lines can be problematic. Going to a domestic violence shelter . Access to shelters is not as universal as sometimes thought. Fewer than half of U.S. counties have shelters, and those shelters that exist are often full. A national survey on shelter services found that, in a single day, there were more than 4,000 unmet requests for shelter or transitional housing (National Network to End Domestic Violence, 2008). In addition to issues regarding access, some shelters have policies that exclude boys over age 13 (or younger) or exclude women who are actively using drugs or alcohol to cope with the effects of the abuse. Other shelter policies may require residents to participate in interventions, such as parent training. Although such policies are generally meant to protect and assist shelter residents, they effectively exclude many victims in need of shelter. Often operating with very limited resources, shelters may struggle to offer culturally relevant services, particularly to battered women who are the most marginalized, such as immigrants, women of color, women with disabilities, lesbian, gay, bisexual, and transgender survivors of domestic violence, and battered women charged with crimes. In one nationally representative community survey, 4% of women who left their partner went to a safe house or homeless shelter (author's analysis of archived data from Tjaden & Thoennes, 2000). Another study found that 10% of domestic violence victims sought help from a shelter (Cattaneo & DeLoveh, 2008). A recent study of 3,410 shelter residents in eight states found that, after time in shelter, 92% felt more hopeful about the future, 91% knew more about their options and ways to plan for their safety, and 85% knew more about community resources – outcomes associated with longer-term safety and well-being (Lyon, Lane, & Menard, 2008). Although not used by all victims, emergency shelters serve as an important protective strategy, especially for the most severely abused women and those with the fewest financial and social resources. Utilizing other domestic violence program services. Although shelter is the service most closely identified with anti-domestic violence programs, most programs offer a variety of services, usually at no cost. Existing data suggests that the most commonly utilized domestic violence-related services include providing information about domestic violence and referrals to other organizations (North Carolina Council for Women, 2007). Indeed, these services are provided more than 10 times as often as shelter. Transportation, court accompaniment, and counseling are also provided more frequently than shelter. Some racial groups utilize program services more often than others. In North Carolina, which keeps one of the largest databases on domestic violence services, three racial groups comprised larger portions of clients served than they do of the total North Carolina population: African Americans, Hispanics, and American Indians. Two groups were somewhat underrepresented in comparison to their numbers in the population: Whites and Asian Americans. It is possible that racial and ethnic differences in service utilization are due to lower income individuals being overrepresented in some U.S. minority groups. Research demonstrates that lower income women are more likely to use shelters than women with higher income (Cattaneo & DeLoveh, 2008), and may also be more likely to seek help with transportation and other services. Data suggests that a variety of program services are used by large numbers of victims. However, interpreting service data is complex because some of these services are provided to women while they are in shelter. Shelter “service” can comprise as much as a 90-day stay, while other services take place over much briefer periods of time. Further, not every anti-domestic violence program has the resources to offer shelter, and shelter might be used more if it were more widely available. Finally, as these data come from programs, not victims, one cannot determine what percentage of victims use these various services as part of their coping strategies. Reaching Out for Social Support Most women seek social support by disclosing their experiences of abuse to family members, friends, neighbors, and/or co-workers. Social support may provide women with needed validation, another perspective on the situation, support around safety planning, assistance with holding the abusive partner accountable, and a counterbalance to the batterer's minimization, denial, and blame. Social support may also result in tangible offers of help, including places to stay, financial assistance, or places to store belongings in case of emergency. Like most protective strategies, though, seeking social support does entail risks, as women might instead encounter fear, rejection, and stigma. Despite these risks, most battered women do seek social support. Three studies found the rate of confiding in a friend or family member to be over 90% (Goodkind, Gillum, Bybee, & Sullivan, 2003; Levendosky et al., 2004; Rounsaville, 1978). Another study found that 74% sought help from at least one friend and 47% sought help from family (Yoshihama, 2002). In another study, approximately two-thirds sought support from their own family, while over 40% sought help from friends (Strube & Barbour, 1984). In a sample of Vietnamese immigrants, 62% talked with relatives, friends, or religious leaders (Bui, 2003). Although the total number of people confided in is not often measured, Goodkind et al. (2003) reported that more than half of their sample (56%) talked to both family and friends. Social support can be emotional support and also more direct support. According to one nationally representative survey, 68% of women who leave their partners go stay with family members or friends (author's analysis of archived data from Tjaden & Thoennes, 2000). Turning to Spiritual and Religious Resources One of the great disservices to many victims of domestic violence is the frequent categorization of prayer and other spiritual strategies as “passive” or “avoidant” coping. Prayer, and other spiritual ceremonies and resources, may be a great source of strength for women from many cultural and ethnic backgrounds (Hamby & Gray-Little, 2007). Hage (2006) found that faith in God was important to the coping of 90% of the battered women in her sample. Similarly, El-Khoury et al. (2004) found that 88% used prayer to find strength and guidance, and 27% talked to a member of the clergy about their abuse. Spiritual practices are often reported more frequently by women of color, including African American women (El-Khoury et al., 2004) and Muslim women (Hassouneh-Phillips, 2001, 2003). Culturally specific spiritual practices may play an important role in the process of healing and protection, as exemplified by the statement of this American Indian woman from the Seattle area: …That helped me a lot, … smudging [ritual purifying with the smoke of sacred herbs such as sage] and just doing a lot of different things about being strong and protecting myself, you know. The Native person can teach me how to protect myself in a Native way, like smudging, and not cutting my hair, and just leaving it on the ground so someone can stomp on it! And you know, just things like that, little things. And the music, powwow music was a big healing for my heart and made my heart strong again (Senturia, Sullivan, Cixke, & Shiu-Thorton, 2000, pp. 114-115). Some women, however, report that their partners use scripture to enhance power and control over them, or that the rules of some organized religions hamper their efforts to protect themselves (Hage, 2006; Hassouneh-Phillips, 2001, 2003). More needs to be done to craft ways of simultaneously supporting women's spirituality and right to safety. Use of Traditional Health, Mental Health, and Social Services Fairly large numbers of women seek help from psychologists, social workers, physicians, drug and alcohol abuse treatment providers, community health centers, and other health and social service providers. Some significant impediments to the use of these services exist, including financial costs, concerns about confidentiality, and access to providers with training in domestic violenc