 Okay, so as Carol said, I am a social epidemiologist, so I'm coming from quite a different disciplinary perspective than most of you. And I have to say for me it's been really interesting to sit and listen in to some of the summaries and overviews and also about the more recent findings in genetics and neurobiology around sex and gender. So thank you so much to the conference organizers and to Carol for inviting me here. It's been great. So my area of specialty is really around the epidemiology of violence and violence prevention. So this is violence against children and also violence against women. So I've been asked to come and speak to you about some work I've been doing recently on intimate partner violence against women. So in my talk, I'm going to take us through some of the kind of recent prevalence estimates that myself and colleagues have been working on. We're going to look a little bit at some of the health effects of exposure to partner violence and then also consider a bit about what kinds of things we can do to address this violence and how this relates to systems of sex, gender, and power. Okay, so to start out, just to make sure we're all on the same page, when I'm talking about intimate partner violence, what I mean is this. So we normally define intimate partner violence as actual or threatened physical or sexual or psychological violence directed toward a spouse, ex-spouse, current or former boyfriend or girlfriend, or current or former dating partner. And the former partner aspect of this definition is quite important because we often find that risk of partner violence is heightened during that period of immediate relationship breakdown and right afterwards. So intimate partner violence is actually one of the most common forms of violence against women and also one of the most studied forms of violence against women. So other terms that you might have heard to describe this are things like domestic abuse, spousal abuse, courtship violence, battering, marital rape, date rape. All of these things fall under the umbrella of intimate partner violence. And we definitely see, I would argue kind of in the global literature, that this form of violence primarily involves aggression by men against female intimate partners. It's very important to recognize that this violence can also take place in same-sex relationships, certainly, and also by women against men. So when we think about what sorts of behaviors are included in definitions of partner violence, there's been a lot of research kind of going into thinking about how to measure this well. We tend to ask people about their experience of behaviorally specific acts. So in this category of physical violence we'll ask things like have you ever been slapped, kicked, burned or strangled by a partner for sexual violence? Have you ever been coerced or physically forced to have sex? And psychological violence also encompasses a range of things. So that's things like have you been isolated by your partner, prevented from seeing your friends, prevented from seeing your family? Has there been verbal aggression against you? Have you been humiliated? Does your partner kind of control access to health care or reproductive technology, for example? And it's important to keep in mind when we're thinking about this that partner violence can be a pattern of these acts which are occurring on an ongoing basis over time. So why is this actually important to think about and why now? And in terms of that I would say two things. I think one, violence in general, violence against women and children in particular are having a bit of a moment kind of on the international policy and development agendas. And so I don't know if people are familiar with the Sustainable Development Goals. They're sort of the successors to the Millennium Development Goals. But gender equality is actually going to be one of these new SDGs that everyone is signing up for. That little symbol in the corner there, it's goal number five. And it's actually, which is great news in and of itself. So for the first time we've got this as kind of an explicit target that people are trying to reach. And in terms of intimate partner violence it's actually looking like the national level prevalence of intimate partner violence will be adopted as one of the indicators to measure successful progress towards achieving SDG goal number five. And so kind of a concomitant with this, there are some major donors certainly in the UK and European space who are putting some serious money into research looking at the epidemiology of these forms of violence and what we can do about them. Which is exciting news I think for the field. The other thing I would say about why this is important and obviously considering the theme of the conference is that I think for all of us questions of violence and kind of aggressive behaviour and how these come about are very much intertwined with questions about sex and gender. And I think there are a range of theories on the kind of ideology of violence and aggression and these emphasize everything from very kind of upstream macro level societal and cultural factors to very kind of micro level individual kind of genetic and psychological factors and thinking about what contributes to aggression. So for example and I'm definitely oversimplifying here but I think that some kind of classical feminist theory would posit that men's violence against women is very much an expression of patriarchy and patriarchal control and that kind of unequal societal level institutions are an important causal factor in maintaining violence against women. At the other end of the spectrum I think we've got some other theorists that pay much more attention to the role of kind of individual psycho pathology and explain why some individuals are more violent than other individuals. I think these days in epidemiology and public health we tend to take a bit more of an integrated approach but certainly I think violence and aggressive behaviour remain a very interesting space in which to think about how culture and biology interact to produce behaviour. So now that we've all agreed about what intimate partner violence is how much of a problem actually is this? And we were lucky a few years ago we had the opportunity to actually make some estimates of the global prevalence of intimate partner violence against women and this was in connection with a large project called the global burden of disease study which might be familiar to you if you're in public health and I think someone put up some data from it earlier so it's a large global collaboration where lots of different people are working on kind of figuring out the prevalence health effects and health burden of a range of different conditions so our little part of that was to look at partner violence against women. Okay, so I'm not going to tell you too much about the methodological detail but basically how we made our prevalence estimates was to do a lot of systematic reviews I don't know if people here do systematic reviews but if you've ever done one you know what a slog it is. See how it gets? So for this particular set of reviews we searched loads and loads of databases screened 26,000 abstracts which obviously took quite a while and we were really looking for population based studies here so we were only taking studies that were representing some kind of geographical area. In making our estimates we were only able to include physical and sexual intimate partner violence so emotional violence wasn't included in our estimates and that's because there is a relative lack of data on this form of violence globally so people are good at measuring physical and sexual stuff the emotional stuff not so good across cultures. Okay, that was actually the same reason why we didn't also make estimates of the prevalence of partner violence against men there is definitely a lack of good comparable data on that globally. So in addition to these systematic reviews and I think where we really kind of added value to the literature that was out there we also did a lot of secondary analysis of these big international population based surveys which have come out very fuzzy on that screen, sorry so there's studies like the WHO multi-country study on women's health and domestic violence against women that's done in 10 countries international violence against women surveys another set of studies called Genesis and of course the demographic and health surveys which have data from now upwards I think 50 countries have measured domestic violence using the DHS module. So we were able to do additional analysis of a lot of these data sets and really get a lot more information on women's experiences of violence. Then what we did after gathering all this information was put it all together and we put it together to make estimates of the prevalence of violence. So what we ended up having was data from 141 studies in 81 different countries and we put these all into a meta-regression model and through this modeling we were able to kind of take studies that were varying slightly in quality and had different design characteristics and kind of correct for those and the other thing that we did in our estimation which people don't tend to do or passed attempts to compile this data that we haven't done was that we were able to weight our estimates so that they reflect the real-life kind of age structures of different country populations if that makes sense. So the estimates we produced are reflecting the real-world situation in the year 2010. Okay, so that's the kind of methodological stuff. So after a lot of work we came up with our global estimate of the prevalence of partner violence and normally I ask people to guess what this is but I've gone and written it in the abstract so I can't ask you that now. So this was the big number, 30% and you probably can't see it because of the chairs but this is 30% of women who report experiencing physical and or sexual intimate partner violence in their lifetime. So a pretty big number. Any reactions to that number? Maybe it's an underestimate. Yeah. Underestimate. Is anyone surprised by that number? Because you're stating this is in their lifetime, correct? Yeah. So I think we hear so much about it now. Yeah, okay. So basically you guys aren't surprised and you think it might be an underestimate. I think that speaks volumes about the audience that I'm talking to. So most people actually find this number quite shocking and I think it's because this still is actually quite a hidden problem. So women experience this but in a lot of settings it's still quite stigmatized and they don't disclose. So in one of those big international studies that was done in 10 countries they interviewed 24,000 women and they asked at the end of the interview have you ever told anyone about this before? And more than half of the women said no. So the first time they ever disclosed was during that interview for data collection. Yeah. So despite this huge prevalence this still remains a relatively hidden problem. So this 30% is our big global average. That is masking a fair amount of regional variation, okay? So this is the percentages by WHO region which just depending on your perspective may or may not make a lot of sense. So they're very large regions. They're political groupings. But what we can see even in these big regions is that we've got prevalence around 37% in the African region Eastern Mediterranean and Southeast Asia and then at the other end of the spectrum in the high income countries we've got a prevalence of just over 23%. So quite a lot of difference. And we've also, in our paper this is actually broken down into further sub-regions. So if anyone's interested in more detail you can look there and that's even showing a wider range of variation. Okay. So this is a very common form of violence clearly. Being in public health we like to think about the health impact these sorts of things. So what are the health impacts? And it turns out there's sort of multiple pathways by which exposure to partner violence can impact your health. And what we see is that in addition to the kind of more obvious pathway of physical trauma and injury that can result from partner violence there are pathways to adverse outcomes that stem also from psychological trauma and stress. And also very importantly as a result of fear and control and the effects of these on women's behavior. So including limitations on her ability to control her reproductive health and ability to seek health care. And I think for a long time people are really only talking about this pathway where physical assault can lead to injuries which then in turn increase risk of disability and death. And looking at this pathway we've shown through another set of reviews which I won't bore you with the methodological details of but basically we found that 42% of women who've experienced just physical or sexual partner violence experienced injuries as a result. So that's clearly an important pathway when we're thinking about health outcomes. We've also found that women who experience partner violence are almost twice as likely to experience depression and almost twice as likely to have alcohol use disorders which themselves then have substantial health impacts. In terms of moving along that way in every productive health outcomes women who've experienced IPV are 16% more likely to have a low birth weight baby and also one and a half times more likely to have HIV or another STI. So if we're thinking about the major drivers of disease burden globally just a lot of the stuff we've outlined here it becomes pretty clear that partner violence is an important factor in thinking about those. And we also found an increased risk of suicide attempts. Another piece of work that we've been doing recently and released a couple of years ago now is around intimate partner homicide. And my colleague, Heidi Stockle, also at the London School she looked at homicide data from all over the world and broke it down by perpetrator and what she found was that 38% of all women who are murdered are actually murdered by their intimate partner. And the figure among men is 6%. And so it's important to note that men generally are more likely to die from homicide in general versus women, but for women their risk is actually coming from inside the home which is supposed to be a protective space. This picture here is actually a quote from Zimbabwe and it's made by families and friends of women who died at the hands of their partners in Zimbabwe. So I've been painting a pretty dire picture here. We know partner violence is very common it's got some pretty severe health effects but is it inevitable? And I personally would say no. And I would draw our attention to the variation we can see between countries. So I think any partner violence is too much partner violence but we actually don't see very, very high levels of partner violence everywhere. So to me this is indicating that there's something going on in some places that makes the places or people in those places less violent than elsewhere. So when we're looking at now past year prevalence of intimate partner violence which is kind of a better measure of what's going on currently in a women's life rather than the kind of lifetime exposure that I showed you previously. So this plot is looking at the prevalence of past year partner violence on the y-axis and then the level of economic development of a country so the GDP on the x-axis and you can see here that there is a relationship between a country's level of economic development and past year prevalence of partner violence. So as economic development increases past year prevalence decreases. And this is a very crude analysis an ecological analysis as we would say in epidemiology. But very recently just in June this year my colleague Laurie Heisey has published a much more detailed multi-level analysis exploring what factors can affect prevalence of violence. And she's shown in this paper that actually some of the kind of gender related factors at a country level including norms around the acceptability of violence and things like property rights for women if you can own land and so forth actually predict individual risk of violence even after accounting for individual risk factors. Okay. So what can we do about all of this violence? You know in my field there's a lot of thinking going on certainly about how to respond to women who experience violence there's a lot of them so how to prevent further violence in that group and other trauma. And there's also a lot of work going on around primary prevention which you know to me if you look at the scale of this problem it's pretty clear that we need primary prevention strategies to stop violence before it occurs. Okay. This is a kind of ecological model to explain partner violence which is sort of the standard approach in public health and so something that recognizes the contributions of both the matter level factors as well as individual makeup to causing violence. We can also situate our intervention research in this bubble and I have to say that research into interventions about how to prevent violence is really in its infancy so there are only a handful of trials really that have used good methods to look at this and test different strategies. I'm a bit short on time so I'll just highlight a couple of different areas where there's different types of interventions. These are based on these areas there's evidence around interventions that work and some are plausible areas based on what we know about risk factors for violence where we should try to test interventions. So the areas where we've got evidence of interventions that work are in the bottom right corner on transforming norms so interventions that use community mobilization for example to change people's ideas about violence as normative behavior those work to prevent violence interventions around improving relationship skills and communication strategies those work to prevent violence Interestingly interventions that reduce triggers so in very poor households for example there's a kind of daily economic stress that comes when the woman's got to ask for a man for money to buy food maybe he's been out drinking the night before or maybe he got fired from his job he doesn't have any money there's an argument and that results in violence so there's some evidence about relieving those immediate economic pressures and other situational triggers that can work to reduce violence. In the kind of the upper arc there I think these are all very areas where we could develop and should develop interventions and test them but we're a little bit light on evidence at the moment okay I'm running out of time so I'm going to wrap up there but just in conclusion I think it's clear from our data that the prevalence of this form of violence is very high but actually there's also a lot of variation between different groups so that to me says that intimate partner violence is certainly important and we have a lot of different strategies that we can try to help prevent this form of violence and I think the underlying thing that some of these interventions that we have seen work are doing is they're kind of uncoupling the notions of violence and masculinity being so intertwined so they're providing alternative masculinities for men where they can be good men by doing things other than being violent towards their wives okay I'll stop there