The Chief Public Health Officer's Report on the State of Public Health in Canada 2016 - A Focus on Family Violence in Canada

A message from Canada's Chief Public Health Officer

Families are the building blocks of our society and a safe haven to nurture children and our intimate relationships. Yet, some Canadians families are in crisis and the statistics are staggering. For many, this report may be difficult and disturbing to read.

In 2014, 131 Canadians died at the hands of a family member and there were 133,920 reported victims of dating or family violence, with the majority of victims being women. Just under 9 million Canadians have reported experiencing abuse before the age of 15 years.

Family violence impacts health beyond just immediate physical injury, and increases the risk for a number of conditions, including depression, anxiety, post-traumatic stress disorder, as well as high blood pressure, cancer and heart disease. Despite the work of many researchers, health care professionals, organizations and communities, we still do not have a good understanding of why family violence happens, nor do we know how best to intervene.

This report sheds light on a topic that can be hard to talk about. Family violence often remains hidden. Working together, we can unravel why, when, where, how, and to whom family violence happens and improve our efforts to support healthy Canadian families.

Dr. Gregory Taylor
Chief Public Health Officer of Canada

Need help or more information on family violence? Please see the following websites:

• The Public Health Agency of Canada's Stop Family Violence website.
• The Department of Justice's Family Violence website.
• The Status of Women's Preventing Abuse website.
• The Royal Canadian Mounted Police's Family Violence website.
• The National Aboriginal Circle Against Family Violence website.

If you or someone you know are in immediate need of help call 911 or your local police emergency number.

Table of Contents

• Acknowledgements
• Key Messages
• Challenges with data on family violence
• What this report is about
• Impacts on Canadians
• Influencing the risk for family violence
• Life course perspective
  • Child maltreatment
  • Intimate partner violence
  • Mistreatment of older adults
• Preventing family violence
• Closing comments
• References

Acknowledgements

Many individuals and organizations have contributed to the development of The Chief Public Health Officer's Report on the State of Public Health in Canada, 2016: A Focus on Family Violence in Canada.

I would like to express my appreciation to the consultants who provided invaluable expert advice:

• Dr. David Mowat, Canadian Partnership Against Cancer;
• Dr. Daryl Pullman, Memorial University;
• Dr. Elizabeth Saewyc, University of British Colombia
• Dr. Harriet MacMillan, McMaster University, the Preventing Violence Across the Lifespan Research (PreVAiL) Network;
• Dr. Jeff Reading, University of Victoria;
• Dr. John Frank, University of Edinburgh;
• Dr. Margo Greenwood, University of Northern British Columbia, National Collaborating Centre for Aboriginal Health
• Dr. Michael Routledge, Chief Provincial Public Health Officer, Manitoba;
• Dr. Peter Donnelly, President and Chief Executive Officer of Public Health Ontario, and;
• Dr. Peter Glynn, Health Systems Consultant

In addition, I would also like to recognize contributions made by partners and stakeholders who were consulted on the report under tight timelines, including Status of Women Canada, Health Canada, the Royal Canadian Mounted Police, Justice Canada, Statistics Canada, the Canadian Institutes of Health Research, Canadian Women's Foundation, Dr. Nadine Wathen from Western University and the PreVAiL Network, Dr. Debra Pepler from York University and the Promoting Relationship and Eliminating Violence Network (PREVNet) and Dr. Wendy Craig from Queen's University and PREVNet.

I would also like to sincerely thank the many individuals and groups within the Public Health Agency of Canada for all of their efforts related to the development of my report, including representatives from the Family Violence Prevention program and the Health Promotion and Chronic Disease Prevention Branch: Dr. Lil Tonmyr, Jennifer Shortall, Jessica Laurin, Matthew Enticknap, Natasha Kuran, Shanna Sunley, Shannon Hurley, Sherrill MacDonald, Simone Powell, Sydney Millar, Tanya Lary, Tracey Reynolds and Dr. Wendy Hovdestad; and notably the members of my report unit and support staff: Dr. Stephanie Rees-Tregunno, Michael Halucha, Judith O'Brien, Rhonda Fraser, Meheria Arya, Fatimah Elbarrani, Crystal Stroud, Michelle MacRae and Lori Engler-Todd.

Key messages

Family violence is an important public health issue. Its impacts on health go beyond direct physical injury, are widespread and long-lasting and can be severe, particularly for mental health. Even less severe forms of family violence can affect health.

Some Canadian families are experiencing unhealthy conflict, abuse and violence that have the potential to affect their health. Known collectively as family violence, it takes many forms, ranges in severity and includes neglect as well as physical, sexual, emotional, and financial abuse. People who experience family violence need to be supported while people who are abusive or violent need to be held accountable.

Family violence is a complex issue that can happen at any point in a lifetime. In Canada:

• An average of 172 homicides is committed every year by a family member.
• For approximately 85,000 victims of violent crimes, the person responsible for the crime was a family member.
• Just under 9 million or about one in three Canadians said they had experienced abuse before the age of 15 years.
• Just under 760,000 Canadians said they had experienced unhealthy spousal conflict, abuse or violence in the previous five years.
• More than 766,000 older Canadians said they had experienced abuse or neglect in the previous year.

Women, children, Indigenous peoples, people with disabilities, and people who identify as lesbian, gay, bisexual, trans or questioning are at greater risk of experiencing family violence and its impacts. Women are more likely than men to be killed by an intimate partner and more likely to experience sexual abuse, more severe and chronic forms of intimate partner violence, particularly forms that include threats and force to gain control. Women are also more likely to experience health impacts.

Violence against women and children is a public health issue of global importance. Global data show that one out of every three women will experience physical or sexual abuse in their lifetime. Approximately 18% of women and almost 8% of men say they have been victims of sexual abuse as children.

Family violence is complicated - no single factor can accurately predict when it will happen. Different combinations of factors at the individual, family, relationship, community and societal level affect the risk for family violence. Examples of factors include beliefs about gender and violence, and relationship characteristics such as power and control.

People are reluctant to talk about family violence, meaning it often goes unreported. Reasons for not reporting family violence include fear and concerns about safety, stigma, and not being believed. In some cases, people believe it is a personal matter or not important enough. They may also be dependent on the person who is being abusive or violent.

Using what we know about the social determinants of health can help prevent family violence and build effective ways to address it. Approaches to prevention include changing beliefs and attitudes, building safe and supportive communities, supporting our youth, healthy families and relationships and promoting good health and well-being.

More knowledge is needed about the effectiveness of prevention strategies and interventions in different situations.

Challenges with data on family violence

Statistics Canada regularly reports on family violence in Canada through the analysis of data from police reports and population surveys. These two data sources complement each other, but are not directly comparable. Information from child welfare investigations are collected through the Public Health Agency of Canada's Canadian Incidence Study of Reported Abuse and Neglect.

Collecting and interpreting data on family violence can be challenging for many reasons, including:

People are reluctant to talk about family violence.^{Footnote 1-6}

• They fear for their safety or the safety of their children.
• They depend on the family member who was abusive or violent.
• They have feelings of blame, shame or denial.
• They think that no one will believe them, that they will be blamed or judged or that they will be arrested.
• They do not want anyone to know and feel that it is a personal matter.
• They feel it was minor or not important enough. They addressed it through other means.

There are different definitions of family violence. Not all surveys use the same definition of family violence. Nor do they all measure the same types of family violence.^{Footnote 7},^{Footnote 8} Emotional abuse and neglect are the most difficult types to measure because they are hard to define and identify.^{Footnote 7},^{Footnote 9}

Family violence is difficult to measure:^{Footnote 7},^{Footnote 10-20}

• Police and child welfare data only capture incidents that come to the attention of authorities. Population surveys capture a wider range of incidents, including those that are not reported. Both are important for understanding the scope of family violence in Canada.
• Population surveys do not always measure all forms of family violence or information on how often someone is experiencing it. One piece of data can include a wide range of behaviours.
• Changes in survey data over time can reflect changes in reporting methods or in attitudes that may affect how people answer questions.
• It can be difficult to interpret rates of family violence in small populations. High rates of family violence in small populations can be due to a small number of incidents. In these cases, a small change in the number of incidents can lead to a large change in the rate.
• Data are not always divided into sub-groups. This means there can be limited information for groups at higher risk for family violence, such as Indigenous populations.
• How questions are worded in population surveys can affect the results. This means comparing across different surveys can be a problem.
• Population surveys rely on people's memory of past events. For family violence, these surveys provide reasonably good estimates. If anything, they likely underestimate the issue.

What this report is about

This report explores why family violence is an important public health issue for Canadians.

Healthy families are the backbone of strong and productive individuals, communities and societies.^{Footnote 21-25} They come in many shapes and sizes and are safe havens that provide food, warmth, shelter, security, support, safety and love.

Family violence is an indicator of families in crisis and in need of help. In 2014, 323,643 Canadians were victims of a violent crime reported to the police. For approximately 85,000 of these victims, the person responsible for the crime was a family member.^{Footnote 10}

Only 30% of Canadians said that the police became aware of incidents where their spouse had been violent or abusive. This means that many incidents of family violence never come to the attention of the police. ^{Footnote 10}

What is family violence?

For this report, family violence includes violence, abuse, unhealthy conflict or neglect by a family member toward a family member that has the potential to lead to poor health. In this context, family members include intimate partners. Research on family violence most often focuses on child maltreatment (also known as child abuse and neglect), intimate partner violence (also known as spousal violence, dating violence, domestic violence or abuse) and mistreatment of older adults (also known as elder abuse and neglect).

The following are common types of family violence.

Physical abuse: a physical act such as pushing, hitting, slapping, kicking, pinching, choking, stabbing, shooting, throwing objects or burning.

Sexual abuse: any type of forced sexual activity or sexual coercion at any age. Any sexual contact with a child under the age of 16 years is a crime as is sexual activity that exploits children under the age of 18 years*.

Emotional abuse: words or actions to control, frighten or destroy someone's self-respect.

Financial abuse: control or misuse of someone's money or property.

Neglect: not providing basic needs (e.g., food, adequate clothing, health care, protection from harm)

Exposure to intimate partner violence: when children are aware of intimate partner violence that is happening in their home.

* There are exceptions for non-family members who are close in age. See the Criminal Code of Canada.

Who experiences family violence in Canada?

To understand how many Canadians are at risk for poor health from family violence, we need to know how many Canadians have experienced it. When Canadians were asked questions about family violence, abuse and conflict, data showed that:

• An estimated 9 million or a third of Canadians over the age of 15 years said they had experienced abuse before the age of 15 or 16 years.^{Footnote 2},^{Footnote 26},^{Footnote 27}
• About 760,000 or 4% of Canadians over the age of 15 years said they had experienced intimate partner violence in the previous five years.^{Footnote 10}
• Over 766,000 or 8% of Canadians over the age of 55 years said they had experienced abuse or neglect in the previous year.^{Footnote 27}

Some Canadians are at higher risk for family violence.

• Women are more likely than men to experience more severe and frequent violence from a spouse or someone they are dating.^{Footnote 10}
• Indigenous peoples are more likely to experience family violence than non-Indigenous people. This is especially true for Indigenous women.^{Footnote 10}
• People with disabilities are more likely to experience violence from a spouse, especially more severe types of violence, than people without a disability.^{Footnote 28}
• People who identify as lesbian, gay, bisexual, trans or questioning (LGBTQ) are more likely to experience abuse or neglect during childhood, bullying and violence from a spouse or someone they are dating.^{Footnote 10},^{Footnote 29-31}

Why focus on family violence?

Family violence has widespread and long-lasting effects on health. It is more likely to affect those who are more vulnerable, marginalized or facing inequities. People who experience family violence are more likely to have:^{Footnote 10},^{Footnote 26},^{Footnote 32-71}

• Mental health issues like depression, post-traumatic stress disorder and anxiety;
• Physical health issues like injuries as well as diseases and conditions such as cancer and arthritis, and;
• A shorter life expectancy.

Some people are at higher risk for health impacts, especially for mental health issues. Examples include women, young children, Indigenous peoples and people who experience more severe types of family violence.^{Footnote 10},^{Footnote 26},^{Footnote 32},^{Footnote 60},^{Footnote 72-81}

How family violence leads to poor health is complicated. This makes it hard to know how many Canadians are in poor health due to family violence. Economic costs related to coping with poor health from family violence in Canada are significant.^{Footnote 82},^{Footnote 83} For child abuse and neglect, costs for health care, social services, and personal costs (e.g., therapy) in 1998 were estimated at almost $4 billion per year.^{Footnote 82} For spousal violence, costs for health care in 2009 were estimated at $200 million per year. Costs related to pain, suffering and loss of life were estimated to be $5.5 billion per year.^{Footnote 83}

Addressing violence against women and children is a global priority: Global data estimate that 35% of women have experienced physical or sexual violence in their lifetime. About 23% of women and men experience physical abuse in childhood and 18% of women and almost 8% of men said they had experienced sexual abuse in childhood.^{Footnote 84-86} Beliefs that discriminate against women and children, that support violence and that lead to power and control issues in relationships are some reasons why women and children are at high risk for experiencing violence.^{Footnote 69} In Canada, addressing violence against Indigenous women and girls has become a priority. In 2016, the Government of Canada launched an independent national inquiry into missing and murdered Indigenous women and girls.

Can family violence be prevented?

There is no one reason that can explain why family violence happens. What leads to family violence is a mix of individual, family, social, community and societal factors. ^{e.g., Footnote 87-89} The complexity of family violence has made it difficult to develop effective ways to prevent it. Research is evolving to better identify opportunities and challenges to address family violence.

Because family violence involves individuals, families, communities and societies, everyone is responsible for stopping it. Reinforcing the principles of public or population health can play an important role. Changing beliefs and attitudes, creating safe and supportive communities, promoting healthy families and relationships and targeting populations at risk are all ways to work towards preventing family violence.

What this report covers

This report explores how and why family violence is an important public health issue for Canadians and what can be done about it. Included in this report are the following sections:

• Impacts on Canadians explores the extent of family violence in Canada and its impacts on the health and well-being of Canadians.
• Influencing the risk for family violence examines various individual, family/social, community and societal factors that influence the risk for family violence.
• Life course perspective provides a snapshot of family violence over the lifespan by exploring child maltreatment, intimate partner violence and mistreatment of older adults.
• Preventing family violence looks at how approaches and practices are addressing family violence through primary prevention.

Impacts on Canadians

To stop family violence and its effects on health, we need to understand who is experiencing it and how it affects health. Outlined in this section is a snapshot of who in Canada is experiencing family violence, how much it is costing Canadians and how it can lead to early death and poor health.

Family violence in Canada

In 2014, police reports showed that there were over 85,000 victims of family violence in Canada.^{Footnote 10} When dating violence is included, this number increases to 133,920 victims.^{Footnote 10} About 96,000 of these victims were women and almost 20,000 were under the age of 20 years.^{Footnote 10} Like other types of violent crime, family violence reported to the police has decreased across Canada over the past four years (see Figure 1).^{Footnote 10},^{Footnote 20}

Recent population survey data show that:

• An estimated 9 million or 32% of Canadians over the age of 15 years said they had experienced abuse before the age of 15 or 16 years.^{Footnote 2},^{Footnote 26},^{Footnote 27}
• An estimated 760,000 or 4% of Canadians over the age of 15 years said they had experienced spousal conflict, abuse or violence in the previous five years.^{Footnote 10}
• An estimated 4.2 million or 14% of Canadians over the age of 15 years said they had experienced emotional abuse from a spouse or common-law partner at some point in the past.^{Footnote 10}
• An estimated 900,000 or 3% of Canadians over the age of 15 years said they had experienced financial abuse from a spouse or common-law partner at some point in the past.^{Footnote 10}
• An estimated 766,000 or 8% of Canadians over the age of 55 years said they had experienced abuse or neglect from a family member in the previous year.^{Footnote 27}

When Canadians were asked about their experiences of conflict, abuse and violence in their current or former marriages or common-law relationships, population surveys show that rates have decreased in the provinces, but not the territories (see Figure 2). This decrease appears to be mostly due to the fact that severe spousal violence is decreasing.^{Footnote 4},^{Footnote 5},^{Footnote 10}

Notes on the data: Information was collected from Canadians ages 15 years and older and represents spousal violence experienced in the previous five years. Includes legally married, common-law, same-sex, separated and divorced spouses. Information for the territories was not available for all years. For 2009, caution is needed for comparisons of data because data were collected slightly differently in the provinces and territories.

Why family violence is decreasing is not clear. One reason could be that younger generations are less likely to have experienced family violence than older generations. There are some data to support this idea. In the territories in 2014, 45% of Indigenous peoples between the ages of 45 to 64 years and 26% between the ages of 15 to 34 years said they had experienced abuse or neglect before the age of 15 years.^{Footnote 3} This is not solely related to family violence and may also reflect the residential schools experience. Data from the United States show that women born between 1966 and 1975 were less likely to have experienced intimate partner violence than women born between 1946 and 1955.^{Footnote 91}

Canadian populations and family violence

Certain populations in Canada are more likely to experience family violence, more severe types and/or more severe impacts. Examples include:

Women: For family violence that is reported to police, women are more likely than men to experience family violence at all ages (see Figure 3).^{Footnote 10} In 2014, 57,835 women and 27,567 men were victims of police-reported family violence.^{Footnote 10}

Population surveys show that in their lifetime, women are more likely to be a victim of family violence than men.^{Footnote 84},^{Footnote 85},^{Footnote 92} In 2010, global data estimated that 30% of women experience physical or sexual intimate partner violence at some point in their life.^{Footnote 84},^{Footnote 85} In high income countries, which included Canada, the proportion was 21%.^{Footnote 85} In 2012, data from two cities in Ontario and Quebec showed the following:^{Footnote 92}

• 29% of women and 15% of men said they had experienced emotional abuse from a family member at least once in their lifetime.
• 15% of women and 6% of men said they had experienced physical abuse from a family member at least once in their lifetime.

Canadian data show that women are two to four times more likely than men to experience sexual abuse in childhood or in their marriage or common-law relationship.^{Footnote 10},^{Footnote 26},^{Footnote 93} Police reports and child welfare investigations find that girls and boys are equally likely to have experienced other types of abuse.^{Footnote 58},^{Footnote 71} Population surveys show that women are more likely than men to say they experienced sexual abuse or were aware of their parents' intimate partner violence in childhood. They were less likely to say they had experienced physical abuse in childhood (see Figure 4).^{Footnote 26}

Notes on the data: Information was collected from Canadians ages 18 years and older. Excludes Canadians living in the territories, Indigenous communities or institutions. Does not include full-time members of the Canadian Forces.

Data from a population survey in 2014 showed that 341,502 or 4% of Canadian women and 418,163 or 4% of Canadian men said they had been a victim of unhealthy conflict, abuse or violence within their marriage or common-law partnership at least once in the previous five years.^{Footnote 10} Women were more likely than men to experience more severe types of intimate partner violence, to experience poor health as a result of intimate partner violence and to be killed by an intimate partner.^{Footnote 4},^{Footnote 10}

Indigenous women are also more likely to experience child abuse or violence within their marriage or common-law partnership than Indigenous men. In 2014:^{Footnote 72}

• 14% of Indigenous women and 5% of Indigenous men said they had experienced physical and sexual abuse in childhood.
• 10% of Indigenous women and 8% of Indigenous men said they had experienced violence committed by a spouse or common-law partner in the previous five years.

Indigenous populations: Indigenous populations are diverse and include First Nations, Métis and Inuit. Family violence in Indigenous communities is the result of many factors including gaps in health and social services, lack of safe places or housing, political and historical context, concerns about the justice system and violence being seen as a normal way to behave. Indigenous women who seek help often need to leave their community. This can mean that they have to leave their sources of support and culture behind.^{Footnote 94} Indigenous peoples may be reluctant to seek help due to the stigma and discrimination they can experience in the health care system.^{Footnote 95}

Indigenous peoples are more likely to experience child abuse and spousal violence than non-Indigenous people. In 2014:^{Footnote 10},^{Footnote 72}

• 40% of Indigenous peoples and 29% of non-Indigenous people said they had experienced abuse before the age of 15 years.
• 9% of Indigenous peoples and 4% of non-Indigenous people said they had experienced unhealthy conflict, abuse or violence committed by a spouse or common-law partner in the previous five years.
• 10% of Indigenous women and 3% of non-Indigenous women said they had experienced unhealthy conflict, abuse or violence committed by a spouse or common-law partner in the previous five years.
• Indigenous women were also more likely to report experiencing more severe types of spousal violence and more severe impacts on health than non-Indigenous women.
• Unlike for non-Indigenous women, spousal violence for Indigenous women has not decreased over time.

Intergenerational trauma is a significant issue for some Indigenous communities. For these communities, it is often related to residential schools as well as historical and political contexts.^{Footnote 96-108} Intergenerational trauma happens when a traumatic event not only affects people who experience it, but when it also affects their children and sometimes, grandchildren. For example, children of Indigenous peoples who experienced trauma from residential schools are at higher risk for depression.^{Footnote 100} Other examples of the long-term effects of the residential school experience include loss of traditional knowledge, poor community health, intergenerational stress, disparities in the social determinants of health and disruptions to ethnic and cultural identity.^{Footnote 99},^{Footnote 103},^{Footnote 109},^{Footnote 110}

People with disabilities: People who have a physical disability, health problem or mental health issue that limits their daily activity are more likely to experience spousal violence or sexual violence than people without these types of health issues (see Figure 5).^{Footnote 28},^{Footnote 111-113} This is especially true for women.^{Footnote 114}

Notes on the data: A person with a disability is defined as people who said they had difficulty in their daily lives or had a physical disability, health problem or mental health issue that affected their daily activities. Information was collected from Canadians ages 15 years and older and represents spousal violence experienced in the previous five years. Incidents of physical or sexual abuse happened within the previous five years while incidents of emotional or financial abuse happened at any point.

Lesbian, Gay, Bisexual, Transgendered, Queer, Questioning, Intersex and Two-spirited (LGBTQQI2S) community: Data on family violence in the LGBTQQI2S community are limited in Canada, so it is hard to know the full scope of the issue. In 2014, 8% of same-sex partners said they had experienced intimate partner violence in the previous five years compared to 4% of heterosexual partners.^{Footnote 10} For same-sex partners, this is a decrease from 21% in 2004.^{Footnote 10} Research shows that people who identify as LGBTQ are more likely to experience child abuse and neglect, bullying, sexual harassment from peers, dating violence and violence in a marriage or common-law relationship.^{Footnote 10},^{Footnote 29-31}

For people who identify as LGBTQ, there are several additional factors that can affect their risk for family violence:^{Footnote 29-31},^{Footnote 115-120}

• Family acceptance is a key issue for LGBTQ youth. It can influence self-esteem and social support as well as physical and mental health.
• Lesbian or bisexual women and gay or bisexual men can face challenges related to gender stereotypes. For women, it can be the belief that women are not violent. For men, it can be the belief that men are violent and do not talk about experiencing violence or abuse.
• Other factors include:
  • Stress from being part of a minority group;
  • The threat of being exposed as being LGBTQ;
  • Disclosure of HIV status if relevant;
  • Gender role conflict;
  • Social stigma;
  • Violence external to the relationship, and;
  • Lack of specific support services.

Economic costs of family violence

To date, studies on how much family violence costs Canadians have been limited. Older data suggest that the economic cost of family violence in Canada is high. It is unclear whether or not these costs have changed over time, as data are not available to make the comparison. Data from 1998 estimate that child abuse and neglect costs Canadians almost $16 billion per year (see Figure 6).^{Footnote 82} Data from 2009 estimate that spousal violence costs Canadians almost $7.4 billion per year (see Figure 6).^{Footnote 83}

For child abuse and neglect, the largest costs are related to lost earnings.^{Footnote 82} For spousal violence, the largest costs are related to intangible costs. These costs include an estimate of how much pain, suffering and loss of life that is caused by spousal violence costs Canadians.^{Footnote 83}

Mortality

Violence, abuse and neglect increase the risk for early death by homicide and suicide, as well as from diseases and conditions that are related to family violence.^{Footnote 94},^{Footnote 121-129} Data on suicides related to family violence, deaths by diseases and conditions related to family violence and deaths due to neglect are limited or lacking.

In 2014, there were 516 homicides in Canada. Of these, 131 or 34% of victims were killed by a family member. Like homicides in general, the number of family homicides have been decreasing, from 229 in 1985 to 131 in 2014.^{Footnote 121} Which family member is mostly likely to be accused of a family homicide depends on the age and gender of the victim:

• For infants and children, parents are most likely to be accused of the crime.^{Footnote 130}
• Women are more likely than men to be killed by a spouse, common-law partner or dating partner.^{Footnote 10}
• For older adults, a spouse was most likely to be accused of the crime when older women were victims of family homicide. Adult children were most likely to be accused when older men were victims.^{Footnote 10}

Impacts on physical and mental health

Family violence has widespread and long-lasting impacts on health. When thinking about these impacts, there are a few points to keep in mind:

• Because it happens early in life, child maltreatment provides the clearest example of family violence having long-lasting effects on physical and mental health. ^{eg.,Footnote 59},^{Footnote 131} Child maltreatment changes how children develop, increasing the risk for poor health later in life.^{Footnote 129}
• Even less severe forms of violence can affect health. For example, physical punishment can negatively affect a child's health.^{Footnote 34},^{Footnote 132},^{Footnote 133}
• Research on how intimate partner violence affect health has largely focused on women. When men's health is affected by intimate partner violence, the effects are mostly the same types of diseases and conditions as those experienced by women. ^{eg.,Footnote 73},^{Footnote 146} Women tend to experience a wider range of and more severe impacts on their health than men.^{Footnote 4},^{Footnote 10},^{Footnote 73},^{Footnote 147}
• Not much research is available on how the mistreatment of older adults affects their health and well-being.

Can impacts be 'reversed'? The English and Romanian Adoptees studies examined neglect in a group of Romanian orphans. These orphans showed many developmental delays and difficulties bonding with caregivers. Adoption in the United Kingdom before the age of six months improved many of these delays in most children. Some children who were adopted at a later age also showed improvement.^{Footnote 134-145}

Outlined in Figure 7 is a simplified picture to show how family violence directly and indirectly affects health.

Health impacts on Canadians: In 2014, almost 250,000 or one out of three Canadians who had experienced spousal violence also experienced physical injuries such as bruises, cuts or broken bones. Between 129,000 and 281,000 or 17% to 37% said they were upset, confused, frustrated, angry, hurt, disappointed, depressed, fearful or shocked. About 59,000 or 32% of Canadians who experienced more severe spousal violence said they had similar effects as the symptoms of post-traumatic stress disorder.^{Footnote 10} This represents only a portion of the impacts of family violence on the health of Canadians.

Indirect impacts: It might seem incredible that family violence increases the risk for getting diseases such as cancer and arthritis and that different types of child maltreatment can all affect health in the same way.^{Footnote 32},^{Footnote 61},^{Footnote 160} Researchers think this is happening because different types of family violence are all stressful and increase the risk for risky and unhealthy behaviours:

• Family violence as a chronic stressor: Family violence is stressful. Chronic stress, especially early in life, can lead to poor health.^{Footnote 43},^{Footnote 129},^{Footnote 161-199} There are many theories on why this happens. Examples of the effects of chronic stress include changes to how the immune system works and how cells in the human body divide.^{Footnote 129},^{Footnote 162},^{Footnote 165},^{Footnote 200-203} This might explain how experiencing family violence can increase the risk for getting diseases such as heart disease or dementia.^{Footnote 129}
• Family violence and risky behaviour: Family violence can lead to risky and unhealthy behaviours such as heavy alcohol consumption, drug use, smoking, unhealthy eating and unsafe sex.^{Footnote 60},^{Footnote 204-211} These behaviours increase the risk for a wide range of diseases and conditions. Examples include sexually transmitted diseases through unsafe sex and liver disease through heavy alcohol consumption.^{Footnote 60},^{Footnote 206}

Mental health: Family violence strongly affects mental health.^{Footnote 60},^{Footnote 73},^{Footnote 74},^{Footnote 149},^{Footnote 206},^{Footnote 212} Both child maltreatment and intimate partner violence are more likely to increase the risk for depression, anxiety and post-traumatic stress disorder than the risk for other diseases and conditions.^{Footnote 60},^{Footnote 73},^{Footnote 149} Child maltreatment increases the risk for mental health issues at any age and for all types of abuse.^{Footnote 131} It also increases the risk for problem and delinquent behaviours such as violence, aggression and other types of antisocial behaviour, particularly in boys.^{Footnote 58},^{Footnote 213-215}

Stigma: Family violence can lead to stigma and discrimation, including false ideas that victims are trapped, passive, helpless, depressed, weak or responsible for being a victim.^{Footnote 229-233} The potential for experiencing stigma and discrimination can lead to people being reluctant to seek help.^{Footnote 234}

Other types of impacts

Family violence can affect people's relationships and lives at school and work.

Social relationships: Family violence can affect people's relationships and friendships. Child maltreatment can affect a person's ability to develop healthy relationships and increase the risk for experiencing or being responsible for intimate partner violence. This may be because it also increases the risk for problems dealing with emotions and stress as well as for poor social skills and lower self-esteem.^{Footnote 151},^{Footnote 213},^{Footnote 217-226} People who experience child maltreatment or harsh parenting can have trouble parenting their own children, which can impact the health and well-being of these children.^{Footnote 227} Women who experience intimate partner violence can be socially isolated. They are also more likely to have difficulties in their family and social relationships.^{Footnote 149},^{Footnote 228}

School: Child maltreatment can lead to poor academic performance and problems at school. This is likely due to the fact it affects learning, memory, problem solving, attention and emotion.^{Footnote 129},^{Footnote 213},^{Footnote 235-241} This can lead to increased risks for financial problems and unemployment in adulthood.^{Footnote 242}

Work: In Canada, over 50% of people who experienced intimate partner violence said that this violence also occurred at or near where they worked. Women were more likely to experience this than men.^{Footnote 243},^{Footnote 244} People who are experiencing intimate partner violence may often miss or be late for work, be less productive at work, and have trouble concentrating on their work or keeping a job.^{Footnote 244-248} Having a job and being financially independent can be important as it provides people with the means to end a violent or abusive relationship.^{Footnote 249} Co-workers can also be affected by people experiencing intimate partner violence, most often by being stressed or concerned about the situation.^{Footnote 244}

Factors that affect the health impacts of family violence

Not everyone is at equal risk for poor health from family violence.^{Footnote 250} Outlined below are some examples of factors that affect this risk:

Resilience: Resilience is when someone is able to cope with or recover from a negative experience or stressful situation with little effect to his or her health.^{Footnote 250},^{Footnote 251} While family violence affects the health of many people who experience it, some people are resilient.^{Footnote 87},^{Footnote 151-154},^{Footnote 252-255} Researchers are interested in figuring out why this happens and how this could prevent family violence from leading to poor health.^{Footnote 256}

Genetics and epigenetics: Researchers have found that person's genetic makeup (their genotype) can increase the risk that child maltreatment will lead to depression in adulthood or problem behaviours in adolescence.^{Footnote 257-259} Other genotypes are thought to reduce the risk that child abuse will affect health.^{Footnote 260},^{Footnote 261} Epigenetics may also play a role.^{Footnote 129},^{Footnote 258},^{Footnote 262-269} Stressful experiences in childhood might affect how genes are activated and expressed, which can lead to poor health later in life.^{Footnote 129}

What is 'epigenetics'? Epigenetics is the study of how human biology adapts to a changing environment by altering gene expression and activation. These changes can be passed on to future generations.^{Footnote 270}

Frequency and severity of abuse: There is evidence that the more types of abuse experienced or the more severe and frequent the abuse a child experiences, the higher the risk that child abuse will lead to poor health.^{Footnote 26},^{Footnote 50},^{Footnote 60},^{Footnote 73},^{Footnote 75-77},^{Footnote 203},^{Footnote 271},^{Footnote 272} Other stressful or negative events experienced early in life can add to this effect.^{Footnote 78},^{Footnote 79} A similar pattern exists for intimate partner violence. The more severe and more frequent the abuse, the more likely intimate partner violence will lead to mental health issues.^{Footnote 74}

Understanding early adversity: Child maltreatment is not the only form of early stress or adversity that leads to impacts on health.^{Footnote 273} The Adverse Childhood Experiences studies were important for showing the link between early adverse experiences and health impacts in adulthood.^{Footnote 273-278}

Age: Whether or not child maltreatment affects later health can depend on what age the abuse or neglect is experienced.^{Footnote 148},^{Footnote 224},^{Footnote 229},^{Footnote 235},^{Footnote 236} In some cases, the earlier the maltreatment occurs in childhood, the more likely it will lead to mental health issues.^{Footnote 237}

Gender: Women are more likely than men to experience health impacts from child abuse and intimate partner violence.^{Footnote 10},^{Footnote 26},^{Footnote 32},^{Footnote 73},^{Footnote 74},^{Footnote 80},^{Footnote 87},^{Footnote 279},^{Footnote 280} In 2014, a Canadian population survey showed that in the previous five years:^{Footnote 10}

• 40% of women and 24% of men said they had experienced physical injuries as a result of spousal violence.
• 22% of women and 9% of men who experienced spousal violence said they had also experienced effects similar to the symptoms of post-traumatic stress disorder.

Women are also more likely than men to be emotionally affected and to experience fear in response to intimate partner violence.^{Footnote 4},^{Footnote 10},^{Footnote 281-283}

Influencing the risk for family violence

No single factor can accurately predict when, how or to whom family violence will occur. What leads to family violence is a mix of individual, family, social, community, and societal factors (see Figure 8).^{e.g.,Footnote 44},^{Footnote 87-89} How these factors interact is not simple.^{Footnote 44},^{Footnote 87},^{Footnote 89} Research that aims to understand this complexity is still evolving.

This section outlines factors that influence the risk for experiencing and perpetrating family violence.

Why does family violence happen? It is important to understand why family violence happens in order to prevent it. There are many theories about family violence, but none of them can fully explain it. ^{Footnote 44},^{Footnote 284-290} At this time, theories that state that family violence is a result of interactions between individual, family, social, and community factors best predict why violence happens.^{Footnote 87},^{Footnote 88},^{Footnote 285},^{Footnote 291},^{Footnote 292}

What does risk mean? Research suggests that the higher the number of risk factors someone has, the greater chance for experiencing family violence.^{Footnote 293},^{Footnote 294} However, someone can have all the risk factors for family violence and never experience it. Someone else can have few or no risk factors and still experience family violence.

Individual factors

Examples of factors that increase the risk for family violence include:^{Footnote 4},^{Footnote 10},^{Footnote 11},^{Footnote 27},^{Footnote 44},^{Footnote 68},^{Footnote 74},^{Footnote 81},^{Footnote 87},^{Footnote 92},^{Footnote 93},^{Footnote 151},^{Footnote 254},^{Footnote 286},^{Footnote 293-297}

• A history of child abuse or neglect
• Age
• Gender
• Traits, beliefs and behaviour
• Physical and mental health
• Substance use
• Stress

Many of the same factors increase the risk for being abusive or violent and being a victim of family violence.^{Footnote 4},^{Footnote 10},^{Footnote 11},^{Footnote 44},^{Footnote 68},^{Footnote 73},^{Footnote 74},^{Footnote 81},^{Footnote 87},^{Footnote 92},^{Footnote 93},^{Footnote 151},^{Footnote 286},^{Footnote 293-339} Why this occurs is not clear, but it could be important for preventing family violence and its impacts. Some factors increase the risk for family violence in some people and not others. For example:

• In 2014, Indigenous peoples were more likely to be a victim of a violent crime, including family violence, than non-Indigenous people. For Indigenous women but not men, identifying as being Indigenous increased this risk. For Indigenous men, other factors such as experiencing child abuse, social disorder in communities and neighbourhoods, being homeless, using drugs, or poor mental health increased their risk for being a victim of a violent crime.^{Footnote 72}
• In the United States, certain ethnic groups have higher rates of intimate partner violence. In some cases, factors related to ethnicity (e.g., age, marital status, income) and not ethnicity itself were related to these higher rates.^{Footnote 73},^{Footnote 87}
• Problems with alcohol use such as heavy drinking, are often thought to increase the risk for family violence, but this could be because heavy drinking and family violence have many other risk factors in common.^{Footnote 4},^{Footnote 87},^{Footnote 324},^{Footnote 333} It may also depend on drinking context (e.g., where drinking is taking place, who is drinking).^{Footnote 340}

Three of the more commonly discussed risk factors include:

Gender and intimate partner violence: The United Nations through the Declaration on the Elimination of Violence Against Women and the World Health Organization state that violence against women is a major global public health problem and human rights violation that happens because women are women. It is an act of gender-based violence that increases the risk for harm or suffering in women who experience it. Women are more likely to experience and men are more likely to be responsible for sexual abuse and more severe or controlling intimate partner violence.^{Footnote 280},^{Footnote 328},^{Footnote 341},^{Footnote 342} For less severe forms of intimate partner violence, it is less clear whether or not there are gender differences. ^{Footnote 10},^{Footnote 73},^{Footnote 280},^{Footnote 341},^{Footnote 342} Currently, there is much discussion in the research literature about this issue.^{Footnote 10},^{Footnote 12-14},^{Footnote 87},^{Footnote 298},^{Footnote 306},^{Footnote 328},^{Footnote 342-345}

History of child abuse or neglect: Many people who are abused or neglected as children do not experience abuse or become violent later in life. For some, there is an increased risk.^{e.g.,Footnote 87},^{Footnote 271},^{Footnote 284-286},^{Footnote 292},^{Footnote 295},^{Footnote 296},^{Footnote 346} Why some people who experience abuse or neglect are at higher risk is not known. Some research has shown that:

• Children who experience more types of abuse, or more severe abuse, are more likely to become violent later in life than children who experience fewer types or less severe abuse.^{Footnote 44},^{Footnote 271},^{Footnote 292},^{Footnote 347},^{Footnote 348}
• Children who experience abuse and have access to safe and stable family relationships or develop supportive relationships in adulthood appear to be less likely to experience or be responsible for family violence later in life.^{Footnote 295},^{Footnote 349},^{Footnote 350}

Problem behaviour in adolescence: Problem behaviours in adolescence such as being violent, criminal behaviour or anti-social behaviour are strongly related to being abusive or violent in relationships later in life. This may be because being violent is seen as seen as a normal way to behave.^{Footnote 87}

What about socioeconomic factors? Family violence is often discussed in the context of poverty, low education and unemployment. Evidence on how these socioeconomic factors influence an individual's risk for family violence is conflicting or complicated.^{Footnote 4},^{Footnote 69},^{Footnote 87},^{Footnote 125},^{Footnote 305},^{Footnote 351},^{Footnote 352} It may depend on other factors such as type of abuse, neighbourhood socioeconomic status and beliefs and attitudes on gender and violence. ^{Footnote 87},^{Footnote 293},^{Footnote 353},^{Footnote 354}

Family and social factors

Family and social relationships bring together people with unique backgrounds and experiences. This adds further complexity to the risk for family violence. Outlined below are examples of family and social factors that increase the risk for family violence.

Parenting can be seen as a continuum.^{Footnote 356}

• Healthy parenting includes some forms of discipline.
• Poor parenting begins to include some forms of irresponsible actions.
• Emotional abuse or neglect involves actions that put a child at risk or expose him or her to trauma, do not meet a child's needs or are harsh or uncaring.

Family dynamics and child maltreatment: Examples of factors that increase the risk for child maltreatment happening in a family include:^{Footnote 44},^{Footnote 68},^{Footnote 313},^{Footnote 355}

• Poor parenting and parental attachment;
• Low parental warmth and responsiveness;
• Parental absence, not being available, lack of involvement;
• Family conflict, low family cohesion;
• Disputes about child custody;
• Dissatisfaction with child(ren),unrealistic expectations, a lack of understanding of the child(ren)'s needs;
• Physical punishment and harsh discipline, and;
• Intimate partner violence between parents.

Strong and stable family relationships can decrease the risk for experiencing child maltreatment or violence later in life.^{Footnote 68},^{Footnote 73},^{Footnote 87},^{Footnote 253},^{Footnote 310},^{Footnote 311},^{Footnote 357}

Relationship dynamics, intimate partner violence and mistreatment of older adults: How the dynamics of a relationship influences the risk for family violence is complicated and hard to study. Explanations and descriptions of what happened can differ between the person who is the victim and the person who is responsible for the abuse.^{Footnote 1},^{Footnote 7},^{Footnote 345},^{Footnote 358},^{Footnote 359} Many of the same factors influence the risk for both intimate partner violence and mistreatment of older adults. Examples include:^{Footnote 69},^{Footnote 87},^{Footnote 92},^{Footnote 290},^{Footnote 298},^{Footnote 324},^{Footnote 325},^{Footnote 357},^{Footnote 360}

• Stress in the relationship;
• Marital status;
• Amount of relationship conflict;
• Trust;
• Dependency, and;
• Relationship quality.

Social factors: Several factors related to friends and family can increase the risk for all forms of family violence. Examples include:^{Footnote 27},^{Footnote 68},^{Footnote 69},^{Footnote 87},^{Footnote 92},^{Footnote 125},^{Footnote 313},^{Footnote 325},^{Footnote 352},^{Footnote 360}

• Having friends who are abusive or violent;
• Unsupportive friendships and unhealthy relationships with other family members, and;
• Being socially isolated and lacking social support.

Community and societal factors

Individuals form families and relationships that form communities and societies. Outlined below are examples of community and societal factors that have been found to affect the risk for family violence.

Cultural differences: How culture affects the risk for family violence is not clear. Some cultural factors that are thought to be related to family violence include:

• Beliefs related to gender, children, relationships and older adults.^{Footnote 68},^{Footnote 69},^{Footnote 87},^{Footnote 333},^{Footnote 354},^{Footnote 361-363}
• The mixing of cultures and cultural change.^{Footnote 364},^{Footnote 365}

Looking at national rates of family violence could help determine the role of culture, but calculating rates across different countries is challenging. Data are not collected in the same way and different definitions are used.^{Footnote 84-86},^{Footnote 351},^{Footnote 354},^{Footnote 367-369} This limits our ability to understand how culture affects family violence across the world. Generally, it is likely that Canada's rates of family violence are similar to global rates:

• The global rate of self-reported physical abuse in childhood was calculated to be almost 230 per 1000 children with little difference found across continents. North America's rate was about 240 per 1000 children.^{Footnote 86}
• The global rate of self-reported intimate partner violence experienced at some point in their lifetime was 30% for women. In high income countries, which included Canada, the rate was 21%.^{Footnote 85}

Rates of intimate partner violence against women are higher in countries where gender inequality is higher.^{Footnote 354},^{Footnote 363} Rates of intimate partner violence against men are higher in countries where there is more gender equality.^{Footnote 363} This means that different countries likely need to consider different approaches to prevention.

What do people believe? In 2014, global data from developing countries suggested that more than half of teenage girls and boys think intimate partner violence is justified under certain conditions. In many of these countries, girls were more likely to believe this than boys. More education or higher income was linked to teenagers being less likely to hold these beliefs.^{Footnote 366}

Social acceptability and normalization of violence: The belief that violence is acceptable and a normal way to behave can increase the risk for child abuse and intimate partner violence.^{Footnote 68},^{Footnote 69},^{Footnote 87} Exposure to violence can lead to it being seen as normal. Research suggests that men and women who are abusive or violent tend to think being violent is a normal way to behave. They also tend to minimize its impacts.^{Footnote 370},^{Footnote 371} People who experience family violence can also see it as being normal or as an expression of love by their abusive partner.^{Footnote 1},^{Footnote 69},^{Footnote 372},^{Footnote 373}

Neighbourhoods: There are many neighbourhood characteristics that can influence the risk that a family will experience family violence. Examples of these characteristics include:^{Footnote 4},^{Footnote 68},^{Footnote 69},^{Footnote 87},^{Footnote 374-379}

• Lack of services (e.g., legal, health care);
• Lack of willingness to intervene by community members;
• Lack of community connectedness, support and control of behaviour;
• Social disorder (e.g., noisy neighbour, vandalism, people using or dealing drugs, prostitution);
• Neighbourhood disadvantage (e.g., poverty);
• Instability (e.g., people moving in and out of the community);
• Exposure to or worry about violence in the neighbourhood, and;
• Having many stores in the area that sell alcohol.

Life Course Perspective

This section highlights family violence over the life span by exploring some of the complexity related to child maltreatment, intimate partner violence and mistreatment of older adults. The life course perspective explores how experiences can accumulate and interact over the life time.^{Footnote 351},^{Footnote 380},^{Footnote 381} It supports the idea that people can adapt and change and that there is potential to prevent, "reverse" or reduce the effects of negative and stressful experiences such as family violence.^{Footnote 264},^{Footnote 382},^{Footnote 383}

Family violence and the life course perspective: Some evidence suggests that the impacts of family violence can accumulate over the lifespan. For example, women who experienced intimate partner violence were more likely to become depressed if they had also experienced maltreatment in childhood.^{Footnote 384}

Understanding how people and their families change and grow over a life time is important for understanding family violence. Currently, knowledge about family violence over the life course is fragmented. Research most often focuses on child maltreatment, intimate partner violence and mistreatment of older adults as separate topics. Other forms of family violence, such as teenagers abusing parents or abuse between siblings, are also common, but are less recognized and studied.^{Footnote 264},^{Footnote 382},^{Footnote 383}

Child maltreatment

Police and child welfare data show that parents are most likely to be responsible for family violence involving children that is reported to the authorities (see Figure 9).^{Footnote 10}

Notes on the data: Parent - includes biological, step, adoptive and foster parents. Sibling - includes biological, step, half, adoptive, and foster brothers and sisters. Extended family - includes all family members related by blood, marriage or adoption. Spouse - includes current or former legally married and common-law spouses.

Child abuse beyond adolescence: Many surveys on child maltreatment ask about experiences that happen before the age of 15 or 16 years.^{Footnote 10},^{Footnote 26} Abuse by parents does not always stop once children reach late adolescence or adulthood. A recent population survey showed that a small portion of Canadian seniors aged 55 years and older experience abuse from their parents.^{Footnote 27} There is a need to look beyond childhood in terms of parents maltreating their children.

Changes in families over time: Families can change over time and children can be raised in a variety of situations, some of which can increase the risk for child maltreatment. Examples include:

• Blended households (e.g., households with stepparents) with many family problems can have an increased risk for child maltreatment.^{Footnote 385-387}
• Negative family experiences such as divorce increased the risk that child maltreatment will lead to mental health issues.^{Footnote 388},^{Footnote 389}

In some cases, family violence can happen after a separation or divorce. Partners who are violent can also use access to children as a form of control or punishment against the other parent. When separation or divorce removes a child from a violent environment, this can lead to the end of child maltreatment.^{Footnote 390}

Siblings: Siblings can be a key source of support that continues into adulthood.^{Footnote 391-395} Sibling abuse is often overlooked as a form of family violence. It can be seen as a normal part of sibling behaviour, even by siblings themselves.^{Footnote 391},^{Footnote 394} Like other forms of family violence, it can also affect behaviour and health.^{Footnote 391-395}

Indigenous children: Indigenous populations as a whole are younger than non-Indigenous populations. Some Indigenous children are growing up in a different environment than non-Indigenous children where they can experience inequalities such as less access to health and support services, higher rates of poverty, lower life expectancy and higher rates of some diseases and conditions.^{Footnote 396} These inequalities result as part of a broader context that includes marginalization, discrimination as well as social, economic, politicial and historical factors.^{Footnote 396},^{Footnote 397}

Parent abuse: Abuse of parents by teenagers is different from other forms of family violence because parents still have to parent and often hold power (e.g., parents' salary supports the family). Parent abuse can affect health and create strain within the family.^{Footnote 398} Experiencing child abuse or being aware of violence in their parents' relationships can increase the risk of teenagers being abusive towards their parents. Problem behaviour, a weak bond with parents and certain parenting practices are examples of other risk factors.^{Footnote 398-400}

Healthy relationships and Canadian youth: Most Canadian youth say they have good relationships at home. Girls are less likely to report this (see Figure 10). As youth get older, relationships with parents tend to become worse (see Figure 10). Youth with high quality relationships with family, friends and a sense of connection and belonging to their schools and neighbourhood were more likely to say they were in better health than youth without these high quality relationships. Youth in Canada are less likely to report having a high quality relationship with their parent than in the past (see Figure 10).^{Footnote 401}

Intimate partner violence

In 2014, police data showed that:^{Footnote 10}

• Women were more likely to be a victim of a violent crime committed by a family member than by someone outside their family.
• Men were more likely to be a victim of a violent crime by someone outside their family than by a family member.

Which family member is more likely to be responsible for intimate partner violence also differs for men and women (see Figure 11).^{Footnote 10}

Notes on the data: Information collected from Canadians aged 15 to 89 years. Spouse and dating partner include former and current partners.

Dating violence: In 2014, 15% of police-reported incidents of violent crime were committed by a dating partner. For almost 80% of these incidents, women were victims.^{Footnote 10} Dating violence is a concern for teenagers as adolescence is an important time for establishing good relationship skills and patterns.^{Footnote 402} Risk factors for dating violence are mostly similar to those for spousal violence. Friends and parents can play an important role in dating violence.^{Footnote 87},^{Footnote 403} For example:^{Footnote 87}

• A strong relationship with parents can decrease a teenager's risk for experiencing dating violence.
• Having friends who are violent can increase a teenager's risk for being abusive or violent towards someone they are dating or for experiencing violence or abuse by someone they are dating.

What about bullying? Being bullied can increase the risk for experiencing dating violence. Being a bully or being bullied can both increase the risk of being responsible for teen dating violence. ^{Footnote 87},^{Footnote 404-406}

Canadian youth are more likely to report being bullied than in the past (see Figure 12).^{Footnote 24} Girls are more likely to experience bullying than boys. Boysare more likely to engage in bullying than girls.^{Footnote 24} Youth with poor family and social support are more likely to be involved in bullying.^{Footnote 24},^{Footnote 401}

Pregnancy: For many women who experience intimate partner violence, this violence stops or decreases during pregnancy. Survey data from 2006/2007 show that about 1.4% of Canadian women said they had experienced intimate partner violence during pregnancy.^{Footnote 407},^{Footnote 408} Intimate partner violence during pregnancy puts both the pregnant woman and the developing fetus at risk. Problems can include low birth weight, premature birth, poor prenatal care, poor maternal nutrition, inadequate weight gain, risky behaviour, and postpartum depression.^{Footnote 409-412}

Bilateral violence: Bilateral violence is a controversial concept and experts do not agree about its characteristics.^{Footnote 12-14},^{Footnote 306},^{Footnote 345},^{Footnote 413}It occurs when both partners within a relationship are violent towards each other. Understanding this issue is challenging. Data on intimate partner violence are not always collected to reflect that relationships can be complex and dynamic.^{Footnote 87},^{Footnote 345},^{Footnote 414} Data can also span a wide spectrum of behaviours, from unhealthy conflict (sometimes known as common couple violence) in a relationship to severe physical and psychological abuse (sometimes known as intimate terrorism).^{Footnote 342},^{Footnote 415}

Bilateral violence is more common than initially thought.^{Footnote 417} It most often occurs as unhealthy conflict and not as severe abuse or attempts to gain power or control in a relationship.^{Footnote 283},^{Footnote 309},^{Footnote 343},^{Footnote 344},^{Footnote 407},^{Footnote 416},^{Footnote 417}Without question, severe, frequent and controlling intimate partner violence is more likely to be experienced by women and committed by men. It is also most often one sided.^{Footnote 417} Women are also much more likely to be affected by intimate partner violence than men, even when the type and severity of the violence experienced is the same.^{Footnote 279},^{Footnote 280}

Men and women are equally likely to experience less severe forms of intimate partner violence, such as unhealthy conflict.^{Footnote 10},^{Footnote 343},^{Footnote 417}Evidence is mixed and controversial about whether men or women are more likely to initiate bilateral violence. It may depend on the severity and type of abuse or how questions are asked in surveys.^{Footnote 12-14},^{Footnote 298},^{Footnote 343-345} Bilateral violence can affect health.^{Footnote 343},^{Footnote 418},^{Footnote 419}

Mistreatment of older adults

Police data show that 4% of victims of police-reported family violence were 65 years or older in 2014. Adults over the age of 65 years are more likely to experience family violence that has been committed by an adult child or a spouse than by other family members (see Figure 13).^{Footnote 10}

Canada's population is getting older: In 2013, 15% of the Canadian population was over the age of 65 years.By 2030, it is expected this will increase to 22%- 24%.^{Footnote 420} An aging population means that cases of mistreatment of older adults may also increase.^{Footnote 360}

Notes on the data: Information collected from Canadians aged 65 to 89 years. Adult child includes biological, step, adopted, and foster children. Spouse includes current or former legally married and common-law spouses. Siblings include biological, step, adoptive, and foster brothers or sisters. Extended family includes any family member related by blood, marriage, or adoption.

Family and social structure: Older adults can have a complicated family and social structure. For some older adults, institutional care is part of the aging process.^{Footnote 360} Living with family members other than a spouse can also be a reality for some older adults. A shared living arrangement can increase the risk for abuse of older adults, particularly in terms of physical and financial abuse.^{Footnote 92},^{Footnote 125},^{Footnote 351},^{Footnote 352}

Caregivers: In 2012, almost 50% or 13 million Canadians over the age of 15 years said they had at some point in their life, provided care to a family or friend with a chronic health condition, disability or age-related needs. Of those surveyed, almost all caregivers said they are coping well. The more hours spent on caregiving, the less likely they were to say they were coping well. Almost 30% found caregiving to be stressful and almost 20% said their health had suffered as a result of their responsibilities.^{Footnote 421}

Preventing family violence

Family violence is complex, so it is not surprising that there are few interventions that effectively prevent it.^{Footnote 256},^{Footnote 367},^{Footnote 422-424} This section focuses on primary prevention by providing a snapshot of approaches that have been used to prevent family violence at the societal and community level, in families and relationships and for populations at risk.

Creating and enforcing laws and policies

How laws affect rates of family violence can be complicated and it is not clear if they prevent it from happening.^{Footnote 69},^{Footnote 425-430} Evidence from low- and middle-income countries show that laws alone do not appear to prevent family violence. Effectively enforcing these laws and creating societal attitudes that help stop family violence are also needed.^{Footnote 431}

What is happening in Canada? Canada has a strong legal system in place that makes many forms of family violence illegal. The Criminal Code outlines what are violent crimes. Family violence is not addressed by specific laws, but is covered by various criminal offences under the Criminal Code.^{Footnote 434} Most forms of physical punishment are also a crime in Canada.^{Footnote 432-434}

A number of other laws and policies are relevant to family violence. For example, the Criminal Code also contains laws that can protect victims after the offence has taken place. Several provinces and territories have laws specifically targeting family violence and the protection of children.^{Footnote 437} Mandatory reporting laws are in place in Canada, but it is not clear whether are not they are effective at helping to prevent family violence.^{Footnote 436-438}

Developing strategies, frameworks and initiatives

Strategies, frameworks and initiatives aim to provide examples of effective, evaluated and promising practices that programs can use to prevent family violence. It is unclear whether or not as a whole, strategies, frameworks and initiatives help prevent family violence.^{Footnote 68},^{Footnote 439}

What is happening? The World Health Organization (WHO) has identified violence as an important global issue. Its Global status report on violence prevention 2014 provides an overview of all legal, policy, programmatic and other approaches being taken by participating countries. The WHO has also developed several publications related to preventing violence. Working with many partners, the WHO recently published a resource that outlines seven strategies for preventing or reducing violence against children.

In 2014, the World Health Assembly adopted a resolution on strengthening the role of health systems in addressing violence, particularly for violence against women and children. A global action plan was developed and supporting its implementation was part of a resolution at the 69^th World Health Assembly in 2016.

The United Nations includes within its sustainable development goals several that address issues related to family violence. Examples include:

• Eliminating all violence against women and girls, including trafficking and sexual and other types of exploitation, and;
• Eliminating all harmful practices such as child, early and forced marriage and female genital cutting.

Examples of United Nations Conventions and Convenants related to family violence include: Convention on the Rights of the Child, Convention on the Rights of Persons with Disabilities, Universal Declaration of Human Rights, International Covenant on Civil and Political Rights, International Covenant on Economic, Social and Cultural Rights, Convention on the Elimination of All Forms of Discrimination Against Women and Convention Against Torture

The Government of Canada's Family Violence Initiative is a 15 department federal initiative that began in 1988 and is led by the Public Health Agency of Canada. As part of this initiative, the Public Health Agency of Canada also hosts the Stop Family Violence website. This initiative aims to prevent family violence, promote public awareness on its risk and protective factors, work across sectors, and support data collection, research, and evaluation. Canada's provinces and territories have also developed a variety of strategies and frameworks to address family violence, a list of which are available by province and territory.

Increasing knowledge and awareness

Impact of the media: The media can influence beliefs and attitudes about family violence.^{Footnote 445},^{Footnote 446} Media tend to report on more severe cases and represent them as single events. Experts are also rarely involved and cases can be sensationalized. Violence can be discussed using stereotypes, victims can be blamed and excuses provided for those who are responsible for the violence.^{Footnote 445-453}

The goal of increasing knowledge and awareness is to change beliefs, attitudes and behaviours. This includes changing societal beliefs so that family violence is less socially acceptable and not seen as a normal part of everyday life.

What is happening? Public awareness campaigns aim to prevent family violence by raising awareness of the issue. Whether or not they are successful is not clear and difficult to measure.^{Footnote 439},^{Footnote 440} Bystander programs aim to prevent family violence by increasing awareness and encouraging bystanders to act. Some evidence suggests that bystander programs may have promise. Evaluations have shown them to be effective in increasing people's willingness to intervene, but it is not clear whether this prevent violence from happening.^{Footnote 441-444}

For intimate partner violence, feminist activism has played a strong role in influencing policies on violence against women.^{Footnote 454} It has also brought attention to problems with research methods, such as data collection and analyses that do not provide enough detail about gender differences.^{Footnote 342} Some promising practices exist that support boys and men in helping prevent violence against women.^{Footnote 439}

School-based programs exist that aim to increase knowledge and awareness in order to prevent abuse. One focus of these programs is sexual abuse. These programs work to increase children's knowledge and help them develop skills to recognize, avoid and deal with situations that may put them at risk of sexual abuse. These programs appear to have promise, but more evidence needs to be collected on their effectiveness.^{Footnote 455} For programs that aim to prevent violence against women and sexual assault on post-secondary campuses, evaluations have not effectively focused on whether or not they prevent these types of violence.^{Footnote 456},^{Footnote 457}

Surveillance data can provide important information on rates, impacts and risk and protective factors related to family violence. Without quality data, programs are less likely to be successful in achieving their goals.^{Footnote 458}

Creating safe and supportive communities

Neighbourhoods that are united, stable and supportive and that have community members who are willing to intervene tend to have lower rates of family violence.^{Footnote 87},^{Footnote 361} There are gaps in knowledge on how addressing community factors could prevent family violence.^{Footnote 459} Approaches that aim to address risk factors for family violence and improve community safety exist, but they have not been evaluated to see if they prevent family violence.^{Footnote 460-462}

Promoting healthy families and relationships

Supporting and building healthy relationships, particularly by improving parenting and dating skills, appears to be one of the more promising means of preventing family violence.

What about siblings? Some promising practices exist that can help reduce conflict and aggression between siblings. They may also improve relationships with friends and family.^{Footnote 463}

What is happening? There are many programs that support parents or promote positive parenting skills, but for most of them, it is not clear whether or not they prevent child maltreatment.^{Footnote 426},^{Footnote 464-468} Two examples of evaluated programs include:

• Nurse Family Partnership: Developed in the United States, this home-visit program aims to help young, first-time, socially and economically disadvantaged mothers. It was found to prevent child maltreatment and improve other childhood health outcomes.^{Footnote 423},^{Footnote 467} Evidence has shown it to be effective in the United States and the Netherlands over the long term, but not effective over the short term in the United Kingdom.^{Footnote 467-469} A randomized control trial is currently taking place to evaluate its effectiveness in Canada.^{Footnote 470}
• Triple P Parenting program: This is a program for all parents that provides a variety of ways to promote positive parenting skills. Evidence suggests that this program can decrease child maltreatment, foster care placements and hospitalizations, reduce problem behaviour in children, decrease stress in parents and reduce harsh discipline.^{Footnote 440},^{Footnote 471-475} It has been shown to be promising in several countries, but more analyses are warranted.^{Footnote 476-479}

Teen dating violence prevention programs have not been found to be effective as a whole, but a few programs have shown promise.^{Footnote 480-489} Two examples of evaluated programs that target students from grade 8 to the end of high school include:

• Safe Dates program: This school-based program covers topics such as dating violence, gender stereotyping, healthy relationships, conflict resolution, and communication skills. It was found to have no overall effect after a year, but did decrease sexual and physical abuse in teens with a history of dating violence. It did not decrease emotional abuse. The program also changed beliefs on dating violence, improved skills for conflict resolution and increased awareness of support services. It may also decrease other forms of violence.^{Footnote 485-487}
• Fourth R program: Developed in Canada, this school-based program covers topics such as dating violence, violence and sexuality, healthy relationships, and conflict resolution. Parents and schools are also provided with information. This program was found to increase knowledge on dating violence and reduce dating violence in terms of physical abuse, more so for boys than girls.^{Footnote 488} It was also effective for at-risk youth.^{Footnote 489}

Relationship or couple therapy has been found to improve relationships and may be useful for couples at risk for intimate partner violence, although there is conflicting evidence on its effectiveness. Care needs to be taken because therapy can increase violence in some situations.^{Footnote 23},^{Footnote 490},^{Footnote 491} Relationship education aims to prevent problems before they happen. This approach has been found to help couples adjust to becoming parents and reduce negative behaviour and less severe forms of abuse in some cases.^{Footnote 23},^{Footnote 490-496}

Targeting at-risk populations

Approaches for preventing family violence that target at-risk populations such as women, children and youth, older adults, Indigenous communities, the LGBTQQI2S community or people with disabilities are few, not evaluated, need more study or evidence on their effectiveness is conflicting.^{Footnote 115},^{Footnote 125},^{Footnote 351},^{Footnote 360},^{Footnote 423},^{Footnote 424},^{Footnote 439},^{Footnote 469},^{Footnote 497-503} For some populations, priorities for action have been identified.

• The health care system has been identified as a key point for better identifying families at risk for family violence. Some promising programs exist. For example, in the United States, the Safe Environment for Every Kid (SEEK) model has been found to prevent or reduce child maltreatment for high risk families, but less so for low risk families. The SEEK model involves providing on-going training to health care professionals on parental risk factors that affect children's health.^{Footnote 517-519}
• Women: There is a lack of evaluated approaches for all types of intimate partner violence (e.g., perpetrated by men or women, bilateral violence).^{Footnote 424},^{Footnote 439} Preventing violence against women is an important priority and needs a targeted approach due to the fact that women are more likely to experience severe abuse and violence.^{Footnote 342}
• Child and youth: The World Health Organization's INSPIRE: Seven strategies for ending violence against children outlines seven strategies for preventing or reducing violence against children. These strategies include effective, promising or prudent approaches in the areas of laws, norms and values, safe environments, parent and caregiver support, income and economic strengthening, response and support services, and education and life skills.
• Indigenous communities: Communities and experts have noted that culturally relevant interventions that are developed by or with communities are important and needed.^{Footnote 498} Addressing other risk factors such as the availability of and access to services, safe and adequate housing, concerns about the justice system, impacts of colonization, the legacy of residential schools and intergenerational trauma may be effective. Many of these issues were highlighted as part of the calls to action of the Truth and Reconcilation Commission of Canada.

What about targeting risk and protective factors? Programs exist that show promise by targeting factors that increase the risk for family violence, but it is not clear if they are effective at preventing it. ^{e.g.,Footnote 69},^{Footnote 504-516} There is little research on how approaches to prevention can target protective factors.^{Footnote 255},^{Footnote 256}

Closing comments

Family violence in Canada is cause for concern, especially for those who are most vulnerable - women, girls and Indigenous women, but there are reasons to be optimistic for the future.

Family violence over the life course is a relatively new field of research. Since the 1970s, the body of evidence has been growing. Even though we don't yet have a clear sense of why, statistics tell us that severe forms of family violence are decreasing in Canada, as is violent crime. Evidence also suggests that it is possible to prevent, reverse or reduce the impacts of family violence and that some people are resilient to its effects.

This report has raised more questions than it has answered. Why is violence aimed at fellow family members, including children and intimate partners? How can we challenge our assumptions to build new approaches for prevention? Why are certain people more likely to experience family violence? Why are some people resilient to its effects? Why do most people who experience child maltreatment not become violent later in life?

Clearly we need a better understanding of the causes of family violence and how best to help those families in crisis and prevent the violence from happening in the first place. Our understanding is evolving as families and relationships change. Younger generations are growing up in a very different world.

Talking about family violence can be painful. However, it is the only way that we can become a society that accepts nothing less than safe and healthy families for everyone.

References