"Breaking the Silence — Public Health's Role in Intimate Partner Violence Prevention"

ISKANDER: Good afternoon I’m John Iskander with the Office of the Associate Director for Science, and it’s my pleasure to welcome you to the June session of CDC Public Health Grand Rounds Before we move on to today’s important session on intimate partner violence, or IPV, a note about upcoming Grand Round sessions Next month’s session on global tobacco control has been moved to July 24th at 1:00 P.M For information about all upcoming topics, please consult the Grand Rounds website A reminder that continuing education credits for Grand Rounds are available for multiple professional disciplines Details are available through the website listed here, as well as through the Grand Rounds Website For our viewers’ information, an article summarizing the newborn screening Grand Round session was published two weeks ago in the MMWR The article can be viewed and downloaded at cdc.gov/mmwr We have also partnered with Science Clips and the CDC Public Health Library to feature scientific articles relevant to intimate partner violence and public health This month’s selections made by CDC subject matter expert Thomas Simon delve more deeply into aspects of IPV, including economics, clinical screening, the role of alcohol and are available at cdc.gov/scienceclips I also wanted to bring your attention a past CDC museum exhibition entitled “Off the Beaten Path.” “Off the Beaten Path” presents the work of 28 artists from 24 countries, addressing the issues of violence against women and girls around the world and their basic human rights to a safe and secure life Visit the CDC museum website for more information Grand Rounds could not take place each month without contributions from numerous public health professionals, including these individuals whom I would like to acknowledge at this time Today’s CDC speakers include Dr. Howard Spivak and Dr. Lynn Jenkins Today’s partner expert speakers include Kristi VanAudenhove from the Virginia Sexual and Domestic Violence Action Alliance and Debbie Lee from Futures Without Violence It’s now my pleasure to introduce CDC director Dr. Thomas Frieden FRIEDEN: Many years ago, my wife co-founded and then for 15 years ran a center for battered women Over those 15 years, we supported and sometimes temporarily housed families in crisis who were escaping from abusive, violent, and dangerous home situations The first responsibility of government is to provide for a safe and secure environment for all of its citizens And as we work on interpersonal violence, I think we increasingly recognize that means not only violence on our streets or workplaces, but also violence that occurs at home Interpersonal violence is widespread It affects women, men, and children, and for every population it touches, it has profound implications For children, there’s now strong evidence that there are lifelong health and mental health consequences For the economy, there are significant consequences in terms of productivity, in terms of absenteeism, in terms of safety at the workplace We have a big challenge The first is to accurately monitor the level of interpersonal violence and then disseminate that information, our core mission being, starting as always with surveillance, documenting a problem, being sentinels for health The next is to identify what works for prevention and mitigation

and then to work with partners to scale up those strategies One of the biggest challenges in this area is not only the silence and lack of attention that the issue gets in comparison with its importance, but also the difficulty both methodological, and, in some cases, philosophical behind establishing rigorous surveillance to figure out what works in prevention and then to scale that up So, I’m very much looking forward to this Grand Rounds and to future work identifying not only the nature and scope of the problem but the nature and ability to scale up effective strategies to prevent and intervene Thank you ISKANDER: Our first speaker today is Dr. Howard Spivak SPIVAK: Good afternoon Early in my career, I was invited to participate in a panel on violence prevention at the Harvard School of Public Health The person who spoke before me, a woman named Sarah, started by telling the story of a young woman who was married right out of college and within six months found herself isolated from her family and friends, pushed to quit her job, and was experiencing a steady stream of physical and emotional abuse from her husband When she tried to share this with her family, the response was, “It must be something you’re doing Your husband is handsome, successful, and taking good care of you Be nicer to him.” Unemployed, she was entirely dependent on her husband for money, which he dolled out in small amounts Isolated from her friends, she had little social contact other than her husband, who was demanding and controlling about most everything She was afraid to leave fearing what he might do to her, and where could she go anyway? This went on for two years before she was finally able to accumulate a small amount of money and the courage to one afternoon leave the house with a shopping bag full of clothing, buy a bus ticket, and leave the city As Sarah was describing how this woman began to turn her life around, working in a shoe factory and eventually going to law school, it was suddenly clear to me that she was telling her own story This person who I had known for several years as a strong, confident, and successful assistant district attorney had experienced this? How could that be? I found myself looking out across the auditorium, one very much like this one, wondering how many others were sitting out there with similar stories How many times had I sat in an auditorium or on a bus or at a party next to or near somebody with a story like this? All of my preconceived notions were clearly inaccurate, and why did I know so little about this? Fortunately, we know much more than we did at that time, but this was the beginning of my realization and understanding of the magnitude and depth of this largely hidden problem And it is common, for Sarah is just one of millions of women and men with stories like this Intimate partner violence involves physical violence, sexual violence, threats of physical or sexual violence and psychological abuse, including stalking by a current or former partner It can occur among opposite or same-sex couples and can range from a single incident to an ongoing pattern of violence According to CDC data, more than 12 million women and men are victims of rape, physical violence, or stalking by an intimate partner each year Women are two to three times more likely than men to experience injury from partner violence They are also more likely to experience a fear of physical violence and sexual violence from a partner and twice as likely to be killed by their partner than men Violence between partners can start at an early age Approximately 10% of high-school students nationally report being physically hurt by a boyfriend or girlfriend in a one-year period

according to CDC’s Youth Risk Behavior Survey, and we know that these early experiences with dating violence increase the risk of future partner violence in adulthood Experiences with violence can have effects that last a lifetime Partner violence has been linked to a growing list of mental health conditions, such as depression, Post-Traumatic Stress Disorder, and suicidal behavior The list of chronic health problems associated with this exposure is growing, as well, and includes such conditions as Asthma, Heart Disease, hypertension and stroke Partner violence also results in a number of negative sexual and reproductive health consequences Many of these health effects are the result of health risk and detrimental coping behaviors such as binge drinking, smoking and other substance abuse, as well as the reduced use of preventive health care The costs of partner violence are considerable The estimated annual cost is over $8 billion in medical and mental health costs, as well as lost productivity, and this does not include the significant cost to the legal and criminal justice systems, social welfare programs, and other services that are a consequence of partner violence Partner violence is seldom the result of one factor but rather is often the product of individual, social, and environmental factors Some of the factors that increase risk for perpetrating partner violence include a history of engaging in anti-social and aggressive behavior, heavy drinking, witnessing or experiencing violence as a child, marital conflict, and economic stress Partner violence is also more likely to occur in communities with high rates of poverty and disadvantage and where cultural and social norms support violence As is true of many public health issues, central in our role to preventing partner violence is a collection of data to drive action We collect information to identify key populations at risk, inform our prevention efforts, track the problem over time, and evaluate the impact and outcome of prevention efforts One such effort is the National Intimate Partner and Sexual Violence Survey, which is one of the CDC’s newest surveillance systems and will highlighted by the next presenter, Lynn Jenkins A second is the National Violent Death Reporting System, which collects detail data on violent deaths from 18 states, drawing information from medical examiner, coroner, and police reports and linking them together to form a complete picture of these events NVDRS records an average of 450 intimate partner violence homicides of women, men, and children each year Public health also has an important role in supporting research to inform prevention efforts This includes conducting research to better understand the risk and protective factors associated with perpetrating partner violence, identifying which programs, practices, and policies buffer or alleviate these risks, including policies and population level strategies related to reducing the availability of alcohol, improving economic development in disadvantaged communities, and countering common stressors related to intimate partner violence such as employment, housing, and availability of social supports We also need research to determine how to best scale up effective approaches and ensure widespread adoption In addition to research, we are also investing in capacity-building efforts that are setting the stage for communities to do ground-level work This involves data-driven planning in communities to assess needs, building support for primary prevention of partner violence, and developing tools and providing training and assistance to identify, implement, and evaluate strategies One example of this work is the CDC’s Domestic Violence Prevention Enhancement and Leadership Through Alliances Program, or DELTA You will hear a detailed example of this from our third speaker, Kristi VanAudenhove There is a limited but growing evidence base on preventing partner violence Many programs change knowledge and attitudes Few change behaviors Strategies include youth and parent focused programs,

therapeutic approaches with at-risk couples, community based programs, economic and policy approaches Those that have demonstrated effects on behavior in rigorous trials address teen dating violence Less is known about effective programs with adult populations However, by helping teens learn how to establish healthy, nonviolent relationships, we can potentially reduce later partner violence One of our large investments is Dating Matters, which seeks to address the gaps in research and practice with a comprehensive program for youth, their parents, educators, and the neighborhoods in which they live The program, which is engaging the local public health sector, is using evidence-based programs for students and their parents and supporting skills learned with educator training, local policy development, and a youth-focused communication campaign that uses social media and text messaging It also has an urban focus, and to date, there has been little evidence about what works in preventing dating violence in urban communities with high rates of crime and economic disadvantage The program is being delivered in 45 middle schools across four cities and includes a rigorous evaluation, as well as cost analysis And the goal of the program is to promote respectful, nonviolent relationships and decrease emotional, physical, and sexual violence As we have learned in all of our violence prevention efforts, partner violence is a complex problem that cannot be addressed by a single program or by public health strategies in isolation Ultimately, the prevention of partner violence requires collaboration with criminal justice, education, health services, business, foundations, community organizations, media, and leadership at all levels Public health has a solid history of being effective conveners of multidisciplinary and multi-sector initiatives and efforts and must play a role in the reduction and elimination of partner violence I would now like to introduce Dr. Lynn Jenkins JENKINS: Thank you, Howard I’m very happy to be here to talk to you today about a new surveillance system, The National Intimate Partner and Sexual Violence Survey, what we call NISVS NISVS represents a major advance in our ability to describe and monitor sexual violence, intimate partner violence, and stalking on an ongoing basis There are a number of strengths that make this distinctive from any other surveillance system Specifically, the study’s questions are asked in a health context rather than a criminal justice context The survey asks more than 60 behaviorally specific questions referenced over the lifetime, as well as the 12 months prior to the survey The sample includes both landline telephones and cellphones, utilizing the latest technology and advances in telephone survey methods The NISVS sample is also designed to generate the first-ever simultaneous national and state level estimates of these problems NISVS data collection began in January of 2010 and is ongoing In the first year of data collection, we obtained more than 16,000 completed interviews, comprised of more than 9,000 women and nearly 7,500 men More than half, 55% of the NISVS interviews, were conducted via cellphones The 2010 survey was supported by CDC with additional support from The National Institute of Justice and The Department of Defense Subsequent data collection years are funded by CDC Prior to the NISVS 2010 summary report, the most recent public health surveillance data on these issues were from The National Violence Against Women Survey that had been conducted in the mid 1990s Therefore, NISVS provides new benchmark prevalence estimates for intimate partner violence Data from 2010 indicate that approximately one in four women and one in seven men in the U.S have experienced severe physical violence by an intimate partner at some point in their lifetime This includes, for example, instances of being slammed into something, hit with a fist or something hard, beaten, or hurt by choking or suffocating As you heard Howard describe, the definition of intimate partner violence, IPV, includes physical, sexual, and psychological aggression, including stalking In order to encompass this broad definition,

we have developed a composite measure of IPV that includes any physical violence, including slapping, pushing, and shoving, along with more severe physical violence, as well as rape and/or stalking Using this composite measure, more than one in three women in the U.S have experienced one or more of these behaviors by an intimate partner Of these women, 72% reported being fearful when these things happened, 62% were concerned for their safety, and 28% missed at least one day of work or school as a result of this violence This violence starts at a very young age Among women who ever experienced rape, physical violence, and/or stalking by an intimate partner, more than one in five, 22%, experienced some form of IPV for the first time between the ages of 11 and 17 years Nearly half, 47%, first experienced IPV when they were 18 to 24 years of age As described previously when we used a composite measure of intimate partner violence, more than one in four U.S. men have experienced physical violence, including slapping, pushing, or shoving, as well as rape and/or stalking by an intimate partner at some point in their lifetime Of these men, 18% reported being fearful when these things happened, 16% were concerned for their safety, and 14% missed at least one day of work or school as a result of this violence Among men who ever experienced rape, physical violence, and/or stalking by an intimate partner, 15% experienced some form of IPV for the first time between the ages of 11 and 17 years 39% first experienced IPV when they were 18 to 24 years of age NISVS allows examination of the contribution of each form of violence and the overlaps across forms of violence Among victims who reported intimate partner violence, you can see that the forms of violence experienced and the overlaps among them vary by sex For women, 57% reported experiencing physical violence only, while 92% of men reported experiencing physical violence only For women, 4% reported being raped by an intimate partner, and 3% reported being stalked, and 9% reported experiencing both rape and physical violence 14% of women and 6% of men reported experiencing both physical violence and stalking 13% of women reported experiencing all three forms of violence by an intimate partner at some point in their lifetime A range of immediate impacts and longer-term health consequences were assessed in NISVS These are the first national estimates of health consequences related to these forms of violence Overall, 81% of women and 35% of men who reported experiencing intimate partner violence at some point over the course of their lifetime reported at least one health or other impact related to that violence More specifically, of women who ever experienced rape, physical violence, and/or stalking by an intimate partner, 42% reported injuries and 63% reported experiencing Post-Traumatic Stress Disorder symptoms Of men who ever experienced rape, physical violence, and/or stalking by an intimate partner, 14% reported injuries and 16% reported experiencing Post-Traumatic Stress Disorder symptoms NISVS also allows us to look at the prevalence of physical and mental health outcomes among those with and without a history of rape or stalking by any perpetrator, not just intimate partners, or physical violence by an intimate partner And with regard to longer-term health consequences, women who experienced these forms of violence were significantly more likely to report having Asthma, Irritable Bowl Syndrome, and Diabetes Both women and men who experienced these forms of violence were significantly more likely to report frequent headaches, chronic pain, difficulty sleeping, activity limitations, and poor self-assessed physical and mental health compared to women and men who did not experience these forms of violence Because nearly 70% of women and more than half of men who ever experienced IPV first experienced some form of this violence prior to their 25th birthday, NISVS data highlights that we must begin our prevention efforts early As well, it is clear that preventing these forms of violence will dramatically improve the lives of women and men

in the U.S., and our other speaker will address some strategies and opportunities for prevention Planned next steps for the NISVS data specifically include the publication of a report describing sexual violence, stalking, and intimate partner violence by sexual orientation and a report that provides more in-depth information on intimate partner violence, including further exploration of differences between the experiences of women and men To obtain additional information about NISVS, please visit our website I thank you very much for the opportunity to share this information It is now my pleasure to introduce Kristi VanAudenhove VANAUDENHOVE: 33 years ago, I began working in this field as an undergraduate intern I had grown up in a violent family, and I found healing as I did the work I found passion and mentors and inspiration in the vision of a world without violence Nearly a decade ago, that passion and inspiration were rekindled when I saw an announcement about an opportunity to collaborate with the CDC to develop the capacity of state domestic violence coalitions to more effectively prevent intimate partner violence Before the DELTA collaboration with the CDC, coalitions were seeking to end domestic violence by achieving two priority goals — safety for victims and accountability for perpetrators State domestic violence coalitions are membership organizations of community-based domestic violence programs We provide training, support, and resources to those member agencies and often to other community professionals, as well Over the years, I’ve taken many walks on this beach by my home on the Rappahannock river contemplating the lessons of DELTA, which as Dr. Spivak noted, was designed to help coalitions prioritize preventing intimate partner violence and to build their prevention capacity and infrastructure I’m going to speak primarily to Virginia’s experience, so let me speak just a moment to describe Virginia As I’m reminded by my partner’s family at holiday dinners on a regular basis, my knowledge and appreciation is limited because I am not a Virginian And that may be what you need to know about Virginia Virginians are fiercely proud of their history Instituting major cultural changes can be challenging From the national perspective, there appears to be some support for the assertion that Virginia is different than the rest of the nation Before DELTA, the coalition might have heralded the publication of the NISVS data by crediting a policy or practice unique to Virginia for what appears to be a significantly lower likelihood of being a victim of rape, physical violence, or stalking by an intimate partner Because DELTA has taught us some appreciation for data and respect for those who understand and interpret it, we will be paying attention to these numbers over time and seeking guidance from our partners on how best to interpret and apply this information In Virginia in 2011, nearly 64,000 calls were answered by domestic violence hotlines Over 21,000 men, women, teens, and children received face-to-face services, 6,600 people received emergency shelter, and more than 3,000 families requested shelter when shelters were completely full Overall, demand for services has increased more than 10% a year for each of the past three years This increase in demand has come at a time when federal, state, and private funding have all been declining, creating a very stressed intervention system and underscoring the need for prevention DELTA has provided four key ingredients

for building the prevention infrastructure in Virginia — funding, time, structure, and expertise Funding has made it possible to add 2.5 full-time prevention staff at the coalition and one at each of our four community sites to do the work of prevention Time in the form of multiyear collaborative agreements has been an invaluable ingredient — time to learn to build a collaboration with the CDC and with other states to plan and to build new skills Structure has made the funding and the time stretch even further The CDC team has provided training, technical assistance, and valued collaboration all along the way Finally, adding expertise that we had not previously had to the mix is what has made this recipe really turn out well The first thing DELTA did was to change how we think about prevention In public health, we’re familiar with an analogy that describes people being swept up in a river needing rescue Intervention is the act of pulling people from the river so they don’t drown Prevention is the act of moving upstream to figure out why people are getting into the river and addressing the source of the problem Attention is created when you propose to take people out of their intervention roles and send them upstream to search out the problem when there are still people drowning When you can send folks upstream prepared to tackle both the immediate problem and the longer-term solution because you’ve talked with folks being pulled out of the river and have good evidence about the problem and the solutions, the intervention team becomes a valued part of the prevention process DELTA required the participation of coalition executive directors That addition became key in promoting cross-training and including plans with sustained prevention efforts in our coalition’s strategic plan Virginia’s prevention team and all staff and governing body members were trained on the principles of prevention, as well as the desired outcomes of our state intimate partner violence prevention plan The trainings, meetings, regular calls, and e-mail made it possible for staff in Virginia to learn from and communicate with CDC staff, as well as our colleagues in other coalitions This structure accelerated our capacity building, providing ready assistance whenever it was needed We set out to create a sound evidence-informed plan with a strong evaluation component in hopes that some of the prevention initiatives in Virginia would prove to be right for more rigorous research At the start of DELTA, the collaborative considered nearly 100 intimate partner violence prevention programs as models for primary prevention and found that none truly were evidence informed There were education programs that had been well evaluated, but they focused only on individuals and were orientated toward intervention and early reporting of abuse, not prevention There were innovative multi-strategy prevention projects that had yet to be evaluated As the first decade of DELTA comes to an end, there are nearly 100 statewide and community prevention programs to consider for future research These include initiatives focusing on college students, high school age, and African-American youth Early on, the CDC added empowerment evaluators as a part of the team in each state to the DELTA mix to guide us through a planning and implementation process that included evaluation from the start This approach established the role of evaluator as an active participant in prevention The concept of empowerment evaluation was perfect for domestic violence coalitions Power and control are central to our work because the abuse of power is at the core of domestic violence Similarly, the movement has placed a high value on the lived experiences of survivors as sufficient evidence for action Bringing empowerment evaluation to the table made it clear that power would be shared and affirmed the experiences of survivors would be considered a valuable form of evidence in planning for prevention This formed the bridge that made the science and advocacy partnership possible

We’ve been building capacity in four communities across Virginia The axiom “we teach what we need to learn” has never been truer As we have taught rooms full of advocates, law enforcement officers, and educators what we are learning about intimate partner violence prevention, the learning expands We share a common understanding of protective factors We’ve all learned more about developmentally appropriate strategies in our work with youth, and we’ve developed systems to determine the effectiveness of those strategies We’ve been building a statewide community of practice that includes not only the local DELTA projects but any of the domestic violence programs our community professionals that would like to participate College campuses have been particularly eager to participate, and young people organizing on campuses have embraced the concept of a public health approach to prevention Now, it is not unusual to hear them scrutinizing a cool new idea Is it just a one-time activity? Is it based on a sound understanding of risk and protective factors? It isn’t public health nirvana If the idea is really cool, they are still likely to go for it But, it’s a good start for young people who have developed a healthy appreciation for what it takes to really build healthy relationships Our Red Flag Campaign campuses have been taught how to use a targeted media campaign to gather with a series of carefully designed educational programs and activities, to do more than just raise awareness, to change bystander behavior when someone sees that first red flag for dating violence A prevention mindset has permeated our staff, many of whom are pictured here This shapes the partnerships we consider and the questions we ask For example, we are working with several local law enforcement agencies to consider how better data could be collected when they respond to domestic violence felonies, homicides, and suicides, data that could inform law enforcement practice, improve community responses, and promote prevention orientated understanding of perpetration, another example of work that we are beginning in partnership with young adults with developmental disabilities These young adults are at high risk of sexual and intimate partner violence in part because their parents don’t always imagine the possibility that they will be in relationships We’ll be working statewide on strategies to educate parents of children with developmental disabilities about how they can support healthy relationships Prevention is now integrated throughout the work of our coalition It’s the basis of our new vision statement It’s prominent in our strategic plan It shapes the way we do our work each and every day We’re now working with partners who share our goals around preventing violence, promoting healthy relationships, and celebrating healthy sexuality Over the next 10 years, we plan to create the Building Healthy Futures Fund to expand prevention work across the state, funded partially through sales of a specialized license plate with the message “peace begins at home.” I want to express our gratitude to the CDC for opening the door to this collaboration for sharing dedicated program staff, science officers, and leaders It’s now my pleasure to introduce Debbie Lee LEE: Good afternoon I started my work with Futures Without Violence 30 years ago by going to San Francisco General to work with battered women, train emergency room staff, and create protocols For the past four years, I’ve helped lead Start Strong, a dating violence prevention program aimed at middle school, and I have tried out my theories on my middle-school-age son much to his chagrin, particularly when I had a small focus group of his friends inside our van [ Laughter ] Some of you will know us by our old name, Family Violence Prevention Fund We have a 30-year history of developing innovative strategies to prevent domestic dating and sexual violence in child abuse We develop programs to reach men and youth and transform the way health care providers, police, judges, employers, and others address violence Through partnerships with the CDC and state domestic violence and sexual assault coalitions,

Futures has worked to expand the commitment to primary and universal prevention strategies Several prevention programs such as DELTA, Dating Matters, and Start Strong are examples of major initiatives that work to change social norms and move beyond the individual level Most recently, we worked with the CDC to change surveillance questions to gather better data in building the case, particularly for youth Today I want to highlight the progress we’ve made with health professionals as partners and the recent policy changes to prevent and address intimate partner violence Then I will talk about programs and policies to reach new audiences, men, and youth Since 1993, we have been the Department of Health and Human Services’ National Health Resource Center on Domestic Violence Starting with 12 emergency departments throughout the country, it was the first time that doctors, nurses, social workers, and domestic violence advocates sat at the table together as equal partners to address changes in health care practice We have worked to build a consensus of recommended practice on domestic violence with health care leaders based on their needs, what they are willing to do, and understanding the health system’s capacity for change We have made changes to improve professional schooling and training, medical records, charting and coding, as well as encouraging community partnership, policy, and leadership development As a result of the recognition that intimate partner violence is a public health issue, we saw domestic violence become integrated in several of the affordable care act programs For example, beginning this August, health plans will cover screening and counseling for lifetime exposure to domestic and interpersonal violence as a core preventative health benefit, so we are producing a tool kit that will help providers safely identify, assess, and refer victims to local programs Insurance companies will be prohibited from denying coverage to victims of domestic violence as a pre-existing condition And the Affordable Care Act will provide resources to states to address intimate partner violence, particularly in-home visitation programs In addition to changes from the Affordable Care Act, intimate partner violence screening and clinical interventions have been shown to improve the health and safety of women and teens seeking care in reproductive and adolescent health settings, which was recently recognized in the U.S. Preventative Service Task Force Review In looking at the Affordable Care Act opportunities, our organization is working on a variety of practice and policy recommendations Much can be done to support existing programs and services based on age, developmental stage, and gender norms Our hope is that clinical guidelines for violence prevention, which promote assessment, grief counseling, and referral are incorporated into publicly funded programs and school-based health centers, incorporated in well-women visits and ob-gyn exam, and during other key visits in reproductive, adolescent, and behavioral health settings and included in payment reform efforts to reimburse for onsite counseling and support services for patients at risk Moving to talk about work with youth and men, we are also the national program office of Start Strong Building Healthy Teen Relationships Initiative, which has explored innovative and practical solutions to prevent teen dating violence and promote healthy relationships among middle-school youth These communities represent great diversity from the Bronx to the state of Idaho They include health organizations like the Boston Public Health Commission and a number of domestic and sexual assault organizations The initiative has utilized a social ecological model, employing one of two evidence-based in-school curricula and change school district policy Some of their most creative work has included strategies that engage school personnel, parents, older teens, and other youth influencers and created social marketing and addressed social norms There are a number of insights we have had as a learning community First, the middle school years are a key target age group

because many youth begin dating and start establishing romantic relationships for the first time This is a period of social emotional learning and empathy maturity It is the time when peer and social influences are increasing, and at this age, most youth are still responsive to their parents Because tweens and young teens still look to certain adults and older peers for guidance, much of our attention focused on reaching parents of vulnerable youth and utilizing high-school students as influencers As youth mature, we need to move the bullying education that kids are getting in elementary school to healthy relationships promotion and teen dating violence prevention Schools themselves are calling for coordination of bullying, sexual harassment, and teen dating violence policies Schools have been the hub in order to meet youth where they are Messages offered at school are reinforced at community centers, movie theaters, sporting events, and other places where young people congregate The experience of shaping anti-violence and pro-healthy relationship initiatives can turn youth into committed activists who become credible messengers Many of the Start Strong communities have developed youth/adult partnerships that build youth expertise and help adults understand youth culture Online and mobile communication is an integral part of the lives of youth and a focal point of their social engagement Incidents of digital dating abuse, cyberbullying, and sexting have frightened many parents and caught the attention of authorities Online and mobile technology do not cause abuse, but they make it easier for hurt and angry youth to harm the reputation and mental health of others Social media, however, can be used to teach youth responsible technology use, promote appropriate bystander behavior, and disseminate powerful prevention messages I also want to share with you some of the innovative strategies to engage youth implemented by Start Strong Boston of the Boston Public Health Commission For example, they saw the public conversation opportunitiesi n the 2009 dating violence incident involving pop star idols Chris Brown and Rihanna Their survey on the incident, which made headlines, found that nearly half of Boston youths surveyed said she was responsible for what happened, while 52% said they were both to blame Start Strong Boston also went on to hold a summit for parents and youth to promote healthy relationships and prevent teen dating violence through a discussion about breakups These are just a couple of the examples of our community’s innovative strategies I encourage you to check out startstrongteens.org to see more I want to highlight That’s Not Cool, the public education campaign — national — that uses digital examples of controlling, pressuring, and threatening behavior to raise awareness about and prevent teen dating abuse Its target are teens ages 13 to 15 The website is the hub of the campaign and engages teens in a variety of activities about power and control in their relationships, including interactive videos, games, callout cards which they can text to each other, and a tool which allows teens to create their own unique animated characters The campaign was sponsored and co-created by the Department of Justice’s Office of Violence Against Women, The Advertising Council, and Futures Without Violence Eight of the Start Strong sites also use this campaign Another public education campaign is Coaching Boys into Men, which engages men to talk to boys in their lives about violence against women being wrong The coach’s program includes a 12-lesson curricula where coaches teach their young male athletes about the importance of respect, integrity, and nonviolence on and off the field Findings from a recent randomized control trial in 16 Sacramento high schools showed a significant increase in boys’ intentions to intervene when witnessing disrespectful or abusive language or behavior Coaching Boys into Men coaches expressed greater confidence to talk with their athletes about healthy relationships and to intervene when witnessing disrespectful behaviors Congress is considering extending the Violence Against Women Act

for another five years The legislation would continue Project Connect, which has brought together health providers, public health professionals, and domestic violence advocates to make changes in adolescent health, home visitation, and family planning programs It would create a new teen dating violence prevention program with elements common and complementary to dating violence and Start Strong Finally, There is a new purpose area that would support funding to states for prevention and education We’re hopeful that the final Violence Against Women Act will be signed this year and will retain these important prevention sections I’ve seen progress over the past 25 years with the adoption of interventions by health care systems, particularly evidenced-based interventions in reproductive and adolescent health settings, and now we have key policy opportunities to fund this transformation I’m excited by the recent focus on men and youth through programs such as Start Strong, Dating Matters, and Coaching Boys into Men And we look forward to continue work together with CDC and other partners to end intimate partner violence Health and public health leaders and community partners such as yourselves are key to promote healthy relationships and create futures without violence Thank you [ Applause ] SPIVAK: We’re now open for questions We couldn’t have been that clear [ Laughter ] BALDWIN: Grant Baldwin, Injury Center I wonder if you could speak — it was an excellent presentation — about how you message — one of the things that was very compelling to me is the notion of the impact of violence across the life course and how you look — maybe this question is for Debbie — how you look at a youth not exposed to violence and with the sort of evidence-based programs implemented, how their life course changes The trajectory of their life is very different from a middle-school student named Robert or Jen, how their life is divergently variable if they are not exposed to violence and how you utilize that in sort of messaging and getting energy around violence prevention LEE: Wow. That’s a big question Um I will say that most of our work has been around sort of an universal approach So, what I will say is that, one, over the life course, you really do — we do really have to pay attention to where kids are at When you talk about teen dating violence, in our case, when we were doing our program in middle school, sometimes it had resonance and sometimes it did not at all I mean, kids, if they’re not there yet, they really don’t get it, but they do get — they are all about fairness at middle school about teachers being fair, kids being fair to one another And so they are really — there is a lot about this healthy relationship and sort of my right, your right as a middle school student about what you can expect, what you have the right to So, again, that developmental stage is really, really important I think, again, because we were coming from a universal point of view, that resonated with kids who were at risk or not at risk, talking about fairness, talking about — also at middle school talking about bystanders That was a very interesting learning point of view that we found that kids weren’t always willing or knowing what to do, as being a bystander, but they did have a judgment to make And so, for that, I think there’s a lot of future work to think about, and there have been some great programs — Green Dot, other ones — that are moving towards that And teaching kids where — they often say —

well, yeah, they often say they know what’s going on in lots of other friends’ lives but not in their own, which may not always be true, but that’s what they’re saying, too MAN: Two questions First, I believe the YRBS data over the last few years has shown some trends in dating violence I’m wondering if you can comment on those, any theories behind what may be causing any changes with the patterns that we’re seeing, and second, in the evaluation of criminal justice interventions, there have been mandatory arrests or hot-spot attempts to identify families that have called once or more than once and more referrals or interventions, have there been any analysis of these that would help understand what makes for an effective partnership with the criminal justice system? JENKINS: I think that we’re not entirely sure what’s driving the changes in the YRBS data I think one thing that we have been sort of really cognoscente about and I know Debbie mentioned it, is that the question about teen dating violence had a lot of components, it wasn’t very clear, and so it was not a really good measure And so we’re thrilled now that the new question on teen dating violence in YRBS will give us much better data and we’ll have more certainty that we know what we’re talking about when we look at the data Sorry. I apologize But I don’t think that we know precisely what is behind that VANAUDENHOVE: So, in speaking to the question about the criminal justice interventions and the impact as part of our planning process to do our statewide intimate partner violence prevention plans, we were really encouraged to talk with communities, with law enforcement professionals about the trends that they were seeing, to also look at the research on policies And going back even to the question about middle school to talk to survivors about the experiences they had had as middle school, high school, young adults in terms of what interventions made a difference What we know is that exposure doesn’t universally have the same impact on people And so what could we learn about what was helpful to people who made it and were part of this system helping, and what could we learn from folks who are still struggling? And so I think that the lessons around the criminal justice system from the research and from the experiences we heard seemed to be connected to consistency of enforcement, consistency of implementation that the nuances of policy from state to state may not be as significant as how communities embrace and enforce those policies, and that certainly came through in talking to victims and perpetrators, as well And so those kinds of things then became part of our DELTA communities, as part of their prevention initiatives are also engaging their criminal justice system partners, and how can you do your piece to implement effectively and consistently the policies that we do have? WOMAN: Kristi, I appreciate you raising sort of the inherent tension between prevention and intervention, and unless we have an influx of funds that allows us to do both at the level we would want to and that we need to, I was wondering if you have any sort of best practices or good examples whether it’s from Virginia or Debbie You may have some as well in terms of how that tension can be handled in a good way So how is it that we can address both when we, in fact, need to address both at least for the foreseeable future until prevention is really effective and we have less of a need on the intervention side? VANAUDENHOVE: I feel like you all taught us a lot about how to do that And it had to do with going out and engaging people who had been involved in intervention and helping them to see a value to and some hope for doing prevention, and it became — you know, it’s not magic in every community, but for the communities where it’s working, it became a cycle that folks working in intervention are doing that with a prevention mindset,

and so they see their opportunities, whether it’s for direct intervention or for data collection or for partnering differently, and similarly, the folks doing prevention are doing that informed by what’s happening with intervention, and it becomes a cycle that feeds itself And as we have new opportunities like the one I talked about with young people with developmental disabilities, we immediately went to the place of here is the intervention opportunity and here’s the prevention necessity We’re going to do both LEE: I do think that there are different approaches for people who are in the trenches, too, just simple things like about what we’re doing with children who are absolutely in our shelters, et cetera It still does take some resources, which is our challenge, but I think that there are — once people really grasp the frame of prevention, it’s much easier to see ways you slip it in And I think just bringing those questions in and bringing in healthy relationship discussions, teaching moms how to do that can be a big step ISKANDER: I would like to thank all of our speakers I would like to thank Dr. Frieden, and we will see our attendees here and our viewers in five weeks on July 24th for Public Health Grand Rounds on global tobacco control Thank you