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      Using a Multidisciplinary Approach for a Multi-faceted Public Health Problem

      editorial

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          Abstract

          The Emory Center for Injury Control is a multi-university consortium dedicated to studying and preventing unintentional injuries and violence. A major goal of our Center is to transcend academic boundaries and disciplines to connect research to practice. As such, we are focusing our fourth special Western Journal of Emergency Medicine issue on multidisciplinary research. In particular, this thematic issue provides innovative strategies for strengthening new research and adopting new practices that better incorporate injury prevention. For example, one study addresses the need to provide violence prevention strategies in trauma centers, underscoring how many of the youth seen in emergency departments are at increased risk for violence.1 Similarly, there is a need to incorporate protection of vulnerable populations using new strategies and in broader settings. Self-Brown et al2 make a case for including child maltreatment as part of broader disaster planning, and Strasser3 suggests that we address elder mistreatment through screening in legal assistance settings. This issue contains research spanning the lifespan and in varied populations. For example, one study assesses the rates of intimate partner violence (IPV) among men who identify as gay or bisexual, as well as their perceptions of police helpfulness and next steps given their potential need for legal protection,4 while another study assesses individual relationship factors that modulate risk of IPV among men in a same-sex relationship.5 Goldammer et al6 focused on a younger population, investigating factors that influence the probability that a middle or high school student will intervene in a bullying situation, research that lays the groundwork for the development of effective bullying prevention programs. Also focusing on the adolescent population, a qualitative study by Kruger et al7 describes the perspectives of young girls at risk for sexual exploitation, including their experiences with building trusting relationships, peer aggression, sexuality, and sexual commodification in the world around them. Another study, by Barlament et al8, focuses on unintentional injury prevention among adolescents, and highlights the disparity in seatbelt use among teens in rural areas, making a case for interventions that address this problem. With respect to increasing the resources for violence prevention, one of the most powerful arguments we can make highlights the costs of violence to individuals and to our society at large. Roldós et al9 assess the economic burden of IPV in Ecuador and make a powerful argument against the asymmetry of the costs of violence versus the government resources allocated to this issue. Finally, the editorial by Guedes10 makes a compelling case for integrating different forms of violence in research and practice; in particular the authors address the intersection between child maltreatment and IPV and provide a framework accompanying their key points. Similarly, the manuscript by Swahn et al11 focuses on high school students, and examines the overlapping risk factors for violence against others with violence against oneself, as well as the overlap between violence and another important risk behavior – early alcohol-use initiation. These manuscripts point to a critical frontier in violence and injury research: the development of an understanding of how distinct forms of violence overlap and potentiate one another. The research findings in this issue move the field of violence and injury research forward, using a multidisciplinary approach to develop an understanding of violence and injury prevention across the entire spectrum of human development.

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          Gay and Bisexual Men's Perceptions of Police Helpfulness in Response to Male-Male Intimate Partner Violence

          Introduction Despite several recent studies documenting high rates of intimate partner violence (IPV) among gay and bisexual men (GBM), the literature is silent regarding GBM's perceptions of IPV within their community. We examine GBM's perceptions of same-sex IPV: its commonness, its severity, and the helpfulness of a hypothetical police response to a GBM experiencing IPV. Methods: We drew data from a 2011 survey of venue-recruited GBM (n=989). Respondents were asked to describe the commonness of IPV, severity of IPV, and helpfulness of a hypothetical police response to IPV among GBM and among heterosexual women. We fitted a logistic model for the outcome of viewing the police response to a gay/bisexual IPV victim as less helpful than for a female heterosexual IPV victim. The regression model controlled for age, race/ethnicity, education, sexual orientation, employment status, and recent receipt of physical, emotional, and sexual IPV, with key covariates being internalized homophobia and experiences of homophobic discrimination. Results: The majority of respondents viewed IPV among GBM as common (54.9%) and problematic (63.8%). While most respondents had identical perceptions of the commonness (82.7%) and severity (84.1%) of IPV in GBM compared to heterosexual women, the majority of the sample (59.1%) reported perceiving that contacting the police would be less helpful for a GBM IPV victim than for a heterosexual female IPV victim. In regression, respondents who reported more lifetime experiences of homophobic discrimination were more likely to have this comparatively negative perception (odds ratio: 1.11, 95% confidence interval: 1.06, 1.17). Conclusion: The results support a minority stress hypothesis to understand GBM's perceptions of police helpfulness in response to IPV. While IPV was viewed as both common and problematic among GBM, their previous experiences of homophobia were correlated with a learned anticipation of rejection and stigma from law enforcement. As the response to same-sex IPV grows, legal and health practitioners should ensure that laws and policies afford all protections to GBM IPV victims that are afforded to female IPV victims, and should consider methods to minimize the negative impact that homophobic stigma has upon GBM's access of police assistance.
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            Dyadic, Partner, and Social Network Influences on Intimate Partner Violence among Male-Male Couples

            Introduction: Despite a recent focus on intimate partner violence (IPV) among men who have sex with men (MSM), the male-male couple is largely absent from the IPV literature. Specifically, research on dyadic factors shaping IPV in male-male couples is lacking. Methods: We took a subsample of 403 gay/bisexual men with main partners from a 2011 survey of approximately 1,000 gay and bisexual men from Atlanta. Logistic regression models of recent (<12 month) experience and perpetration of physical and sexual IPV examined dyadic factors, including racial differences, age differences, and social network characteristics of couples as key covariates shaping the reporting of IPV. Results: Findings indicate that men were more likely to report perpetration of physical violence if they were a different race to their main partner, whereas main partner age was associated with decreased reporting of physical violence. Having social networks that contained more gay friends was associated with significant reductions in the reporting of IPV, whereas having social networks comprised of sex partners or closeted gay friends was associated with increased reporting of IPV victimization and perpetration. Conclusion: The results point to several unique factors shaping the reporting of IPV within male-male couples and highlight the need for intervention efforts and prevention programs that focus on male couples, a group largely absent from both research and prevention efforts.
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              Examining the Intersections between Child Maltreatment and Intimate Partner Violence

              Intimate partner violence (IPV) against women and child maltreatment (CM) have been traditionally addressed in isolation by researchers, policy makers and programs. In recent years, however, a growing body of research suggests that these types of violence often occur within the same household and that exposure to violence in childhood—either as a victim of physical or sexual abuse or as a witness to IPV—may increase the risk of experiencing or perpetrating different forms of violence later in life.1–4 Moreover, physical punishment of children is more common in households where women are abused and interventions that address child maltreatment may be less effective in households experiencing IPV.1–6 This evidence calls for greater recognition of the intersections between types of violence. We outline 4 specific gaps and present an integrated framework for moving the field forward with respect to the intersection of IPV and CM. 1. NEED FOR CLARITY ABOUT WHAT CONSTITUTES CM AND IPV Researchers disagree on how to define CM and IPV. Regarding definitions of CM, it is unclear if they should include behaviorally specific acts, the perpetrator’s intent, the actual experience of harm and what types of corporate punishments should be considered CM.7 Another question is when and how definitions of CM and IPV should include emotional abuse. Researchers often limit the definition of IPV to physical acts. However, evidence suggests that stressful household environments – such as those plagued by marital conflict and emotional intimate partner abuse – have serious harmful effects on children’s overall development. Unfortunately, defining and measuring “emotional abuse” pose serious challenges to researchers.9 2. NEED TO CLARIFY WHAT WE MEAN BY “INTERSECTION” The intersection of CM and IPV takes many forms. Co-occurrence can be loosely defined as IPV and CM taking place during the same time period within a single family. However, there are questions about the degree to which definitions of co-occurrence should include awareness of co-occurrence by different family members, the definition of family, the definition of the time frame, and the most appropriate unit of analysis (e.g. the family, the child, the adult woman). Even without specific co-occurrence, there are at least 4 other ways in which IPV and CM may intersect. First, they may have similar short- and long-term physical, emotional, and socio-occupational consequences. Second, one type of violence may be a risk factor for the other. Third, IPV and CM may share risk factors and causal mechanisms. Fourth, some prevention and response strategies may be effective for both. 3. NEED TO CONSIDER OTHER TYPES OF VIOLENCE THAT MAY ALSO CO-OCCUR WITH IPV AND CM Researchers have persuasively argued that there is a need to consider multiple forms of childhood victimization (“poly-victimization”), including assaults, bullying and sexual victimization outside the family, CM by parents or caregivers, property victimization, and witnessing violence.10–13 Research shows that two-thirds of children who experienced any type of violence in the previous year had experienced 2 or more types, which further underscores that addressing the relationship between IPV and CM is an important start, but we should expand our focus to examine other forms of victimization as well.10,12 As the framework proposed in the figure shows, addressing poly-victimization and multiple forms of intersections may be complex but has the potential to produce a more complete range of the prevalence of an individual’s total exposure to violence. 4. NEED TO ADDRESS THE GAPS IN KNOWLEDGE ABOUT HOW TO IMPROVE PREVENTION AND RESPONSE TO IPV AND CM As we move towards greater integration of research, policy and programs addressing IPV and CM, the following important gaps in knowledge should be addressed. a) The prevalence of different patterns of co-occurrence of CM and IPV In measuring the prevalence of co-occurrence, 3 denominators are typically used – prevalence of co-occurrence in the general population, prevalence of CM in families in which IPV occurs, and prevalence of IPV in families in which CM occurs, each leading to quite different measures of prevalence. For example, in the United States, the lifetime prevalence of co-occurrence of IPV and CM in the general population is 6%, and the prevalence of CM in families in which IPV occurs is 45%, but these may vary across countries.14–18 b) Consequences of co-occurrence Literature is scarce on the consequences of co-occurrence of IPV and CM for the child victim and few studies have examined the long-term consequences specifically of co-occurrence to adult victims. A key question is whether children who experience CM and exposure to IPV will suffer worse outcomes than those with fewer forms of victimizations by violent exposures.18–22 c) Risk and protective factors Risk factors specific to the co-occurrence of CM and IPV are not well understood, and less is known regarding protective factors and resilience in the aftermath of such co-occurrence. Several theories have informed this area, including social cognitive, developmental-ecological, personality disorder, and family systems theories leading to hypotheses about aggressive individuals and family stress.14,16,17 However, the process of understanding the interplay of risk and protective factors associated with the co-occurrence of CM and IPV is still only in its very early stages. d) Strategies to prevent and mitigate consequences The evidence regarding effective strategies that expressly target the co-occurrence of IPV and CM remains scarce. The presence of IPV can make CM prevention less effective.6 However, CM can be successfully addressed in the context of IPV.23,24 Unfortunately, few rigorously evaluated programs have specifically targeted the co-occurrence of IPV and CM. e) Intersections in the case of non-co-occurrence With regards to the intersections of IPV and CM without co-occurrence, the evidence is limited. Few studies have systematically compared the similarities and differences in the nature and severity of consequences of IPV and CM, for example. CM may be a risk factor for IPV later in life, but few studies have systematically compared the risk factors for CM and IPV and their relative strengths of association. It is imperative that we address CM and IPV with a new and integrated framework that addresses the needs and gaps outlined above. This is a particularly important issue for moving these fields forward and for providing better prevention interventions, medical care and services to victims of violence. It is also of particular importance that these issues are addressed for the benefit of international comparisons and collaborations. As such, we urge our fellow researchers to work with us to address these important issues.
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                Author and article information

                Journal
                West J Emerg Med
                West J Emerg Med
                wjem
                Western Journal of Emergency Medicine
                Department of Emergency Medicine, University of California, Irvine
                1936-900X
                1936-9018
                August 2013
                : 14
                : 4
                : 301-302
                Affiliations
                [* ]Emory University, Department of Emergency Medicine, Atlanta, Georgia
                []Georgia State University, School of Public Health, Atlanta, Georgia
                Author notes
                Address for Correspondence: Debra Houry, MD, MPH. Emory University, Department of Emergency Medicine, 531 Asbury Circle, Annex Building, Suite N340, Atlanta, GA 30322. Email: dhoury@ 123456emory.edu .
                Article
                i1936-900X-14-4-301
                10.5811/westjem.2013.3.16333
                3735375
                23930141
                1998235b-93b5-4fbb-8204-4d60769637ac
                © 2013 Department of Emergency Medicine, University of California, Irvine
                History
                : 13 March 2013
                : 14 March 2013
                : 20 March 2013
                Page count
                Pages: 2
                Categories
                Violence Assessment and Prevention
                Editorial

                Emergency medicine & Trauma
                Emergency medicine & Trauma

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