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2
Patterns of Transmission
of Violence
W
hile it is commonly accepted knowledge that violence begets
violence, many workshop speakers emphasized that epidemio-
logical research methods can reveal the ways in which violence
spreads, both from one act of violence to many and as a spillover from one
type of violence to others. Institute of Medicine (IOM) Board on Global
Health Director Patrick Kelley noted that in epidemiology, when trying to
understand an infectious disease, the methodology begins with a descrip-
tion of the distribution of cases in person, place, and time. Therefore, an
epidemiological survey of the contagion of violence should begin with what
different types of violence exist, who is infected, and where and when the
violence spreads.
Such a methodology is not new to violence research and prevention.
Speaker Valerie Maholmes from the Eunice Kennedy Shriver National
Institute of Child Health & Human Development (NICHD) pointed out
that, in 1993, a National Institutes of Health panel recommended that
research funding priorities in the area of violence should place an emphasis
on the context in which violence occurs, and, 10 years later, NICHD led
an initiative calling for research on the epidemiology of children exposed to
violence. The data presented by many of the workshop speakers highlighted
the epidemiological approaches that have been applied to research on and
interventions to prevent multiple types of violence.
7
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8 CONTAGION OF VIOLENCE
TYPES OF TRANSMISSION AND SYNDROMES
Speaker and planning committee member Gary Slutkin of the Uni-
versity of Illinois at Chicago defined infectious disease transmission as
occurring when an individual or population is exposed to the particular
disease and has an increased likelihood of developing the disease. An indi
vidual who is inflicted with a disease exhibits some form of symptoms,
which vary depending on the disease. Dr. Slutkin suggested that a symptom
of violence can be physically injuring another person; speaker Madelyn
Gould of Columbia University added that self-directed injury also can be a
symptom of violence. Many workshop speakers noted that violence can be
transmitted through either direct victimization or merely through witness-
ing violence.
The incubation period from when the exposure occurs and until dis-
ease symptoms develop can vary. As Forum co-chair Mark Rosenberg of
the Task Force for Global Health stated, “it can be a long time between
something first affecting a person and when it shows up, so [for example]
within a family, children [who are] exposed at a very young age may have
its impact much later.” To highlight the similarity between varying incuba-
tion periods of violence and other infectious diseases, Dr. Slutkin made a
comparison between a young child’s exposure to tuberculosis and child
abuse. In cases of tuberculosis, reactivation of the disease can occur when
the child is in his or her teens or twenties, just as someone exposed to child
abuse may become a perpetrator of dating violence or intimate partner
violence during adolescence or later in life.
Several workshop speakers pointed to research showing that violence
manifests and spreads as different syndromes—collective, interpersonal,
and self-directed—and transmission can result in an infection of the same
type of violence to which an individual was exposed or as a different
syndrome.
Transmission Within Types of Violence
Dr. Slutkin cited evidence that exposure to community violence can lead
to perpetration of community violence (Kelly, 2010). The 2011 London
r
iots are an example of how community violence can quickly spread.
Further ore, large-scale political violence can spread to additional per-
m
petration of political violence, as were the cases in World War II and the
mass killings in Rwanda in the 1990s, which Dr. Slutkin cited as examples.
Like the spread of acts of collective violence, evidence shows that ex-
posure to interpersonal violence leads to additional acts of interpersonal
violence. Speaker and planning committee member Charlotte Watts of
the London School of Hygiene and Tropical Medicine noted that there is
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PATTERNS OF TRANSMISSION OF VIOLENCE 9
evidence of the relationship between intimate partner violence and other
types of interpersonal violence. She cited the relationship between early
exposures to child sexual abuse, violent households, and harsh punishment
as a child, and a woman being more vulnerable later in life to experiencing
violence (Abramsky et al., 2011). Furthermore, she pointed to evidence that
similar early exposure to violence for men is linked to increased likelihood
of perpetrating violence. This early exposure to violence can be the child
being directly violated or witnessing violence in the home. Additionally,
childhood exposure to interpersonal violence in the home can lead to the
child’s perpetration of interpersonal violence against peers later in life,
through bullying and dating violence (Crooks, 2011).
The contagion of self-directed violence also has been shown to exist;
Dr. Gould noted that the evidence base on the impact of media reporting
on suicide, suicide clusters, and adolescent exposure to a suicidal peer has
shown an increase in cases of suicidal behavior, both directly and indirectly
(Gould, 1990).
Transmission Among Types of Violence
Violence spreads not only as one act of violence to many, but as one
act of violence to acts of other types of violence. Many speakers cited evi-
dence of this spread between types of violence. Dr. Watts noted that there is
evidence that suicidal behavior can manifest from exposure to other forms
of violence; women’s experience with intimate partner violence is linked to
increased suicidality (Devries et al., 2011). Similarly, exposure to collective
violence can lead to increased rates of intimate partner violence and other
forms of interpersonal violence. Speaker Eric Dubow of Bowling Green
State University presented evidence that links exposure to ethnopolitical
violence and multiple forms of interpersonal violence. He cited studies that
support ethnopolitical violence as a higher level stressor that increases other
forms of violence at other ecological levels, such as violence within the
community, within the schools, and within the family (Dubow et al., 2010;
Cummings et al., 2010, 2011). In addition to spread through ethnopolitical
violence, exposure to community violence also can lead to an increase in
family violence (Mullins et al., 2004).
Dr. Slutkin commented that the manifestation of family violence re-
sulting from exposure to ethnopolitical violence is particularly interesting
for the disease model because there is no rational explanation why expo-
sure to violence from an enemy would lead to perpetration against family
members. He suggested that this type of transmission shows that violence
spreads not for logical reasons, but because it is a communicable disease.
He compared the manifestation of different syndromes of violence to the
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10 CONTAGION OF VIOLENCE
emergence of different syndromes in other diseases, such as bubonic versus
pneumonic plague.
Understanding the relationship between multiple forms of violence is
important for detecting risk factors for the manifestation of future trans-
missions of violence, and the contagion model can be used to illuminate
such pathways. Dr. Gould provided an example that highlighted the im-
portance of such research, including a study that examined multiple forms
of violence. Such research, rather than that which is singularly focused on
one type of violence, can avoid missing unexpected links among the mul-
tiple forms of violence. For example, suicide clusters are primarily a male
p
henomenon; however, one exception has been among African American
girls in gang-related situations where they have been coerced into gang
membership and sexual behaviors. Their exposure to collective and inter
personal violence has led to an association with a contagion of suicide
within the group.
SUSCEPTIBILITY AND CONTRIBUTING FACTORS
Dr. Slutkin noted that, like other infectious diseases, not everyone
who is exposed to violence exhibits symptoms and many individuals can
act as carriers without serving as a vector. Physical symptoms of violence
are inflicted on those individuals who are susceptible to the disease. Many
speakers discussed contributing factors that affect an individual’s or a popu-
lation’s susceptibility to violence. Many of these factors apply to contagion
within and across multiple types of violence.
Social Norms
Many workshop speakers commented that the contagion of violence
is dependent on norms associated with violence. A disconnection from or
erosion of positive social norms makes individuals and communities more
susceptible to the contagion of violence. In citing an example of youth
violence in New York City, speaker Jeffrey Fagan of Columbia Law School
noted the disconnection between the social norms of the police and the
youth as a contributing factor in the contagion of violence. He suggested
that there is an extraordinary detachment of youth from the social norms
that the police are trying to enforce, which creates a cynicism about the
legal system. The higher levels of cynicism about the legal system lead to
detachment from the moral and social norms of the law and result in higher
rates of violence in those areas. Dr. Dubow noted that there is evidence that
violence resulting from conflicts with out-groups is also generalized toward
in-group members in society, showing a gradual, consistent, and continu-
ous process of erosion of basic social norms regarding violence in society.
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PATTERNS OF TRANSMISSION OF VIOLENCE 11
Many workshop speakers noted that although deteriorating social
norms can increase susceptibility to violence, changing social norms can be
a tool for interrupting the contagion. Dr. Gould noted that recent suicide
preventive interventions are focusing on changing peer norms in schools.
A program for high school students called Sources of Strength is focused
on encouraging students to go to a trusted adult if the student is concerned
a peer may be at risk for suicide. The program works by changing norms
through emphasizing the importance of help-seeking behavior. Dr. Watts
cited violence prevention intervention models and evaluations from Brazil
and from South Africa that show that active engagement of men and boys
to redefine masculinity can reduce the perpetration of intimate partner
violence.
Network Density
Dr. Fagan noted that the contagion of violence is primarily a social
network phenomenon, and increased network density increases the risk of
violence transmission. He cited the social network density within public
housing communities as an example of such a phenomenon. However, the
increased risk is not a factor merely of the density, but the transmission
of norms and cultural software that is amplified and reinforced through
the network structure. Within insular social networks where violence and
danger are learned norms, there is little opportunity to introduce a differ-
ent kind of social norms model that could teach risk regulation behavior
and reduce violence transmission. Dr. Fagan showed a map of incidents
of gun-related violence in New York City. The mapping demonstrated the
formation of co-offending networks that coalesce around individuals who
originally had no or minimal connections, but over time became tighter and
tighter social networks.
Dr. Gould also presented the evidence on suicidal behavior based on
exposure to a suicide within a peer network. She noted that there has not
been that much research in this area, but the majority of the 16 studies
that have been done have found a significant association between being
exposed to a suicidal peer and the subsequent suicide attempt with odds
ratio from 2.8-11.0.
Dose-Response Effect
The dose-response effect, that is, the role of increased and repeated
exposure to violence, was brought up by several speakers. Dr. Dubow com-
mented that the more ethnopolitical violence to which children are exposed,
the greater the occurrences of community, school, and family violence, and
individual aggressive behavior. Dr. Gould cited that more than 50 studies
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12 CONTAGION OF VIOLENCE
on non-fictional stories of suicide reported in the media have consistently
shown that there is a dose-response effect; the more coverage and the more
dramatic the coverage, the greater the increase in suicide rates. The reverse
also has been shown; suicide rates go down following a decrease in the
number of media reports on suicide (Motto, 1970; Hagihara et al., 2007).
Dr. Watts suggested there is a dose-response relationship in the contagion
of intimate partner violence as well; if both the man and the woman come
into the relation with histories of violence, the risk of violence occurring
increases.
Media
Forum member and planning committee chair Rowell Huesmann of the
University of Michigan stated that evidence has clearly shown that media
violence promotes the contagion of violence significantly and substantially.
Dr. Gould highlighted the role of the media on suicide clusters. She cited
that the most consistent finding is related to the dose-response effect,
which is that there are significant increases in suicides when the frequency
of media reporting on suicides increases. In addition to increases based on
the number of reports, there is a greater likelihood of an increase in suicide
when the headlines of the stories are dramatic and when the coverage is on
the front page. Dr. Gould pointed to evidence that interventions targeting
media coverage have been shown to decrease suicide contagion. She cited
an example of media guidelines in Vienna focused on suicides on the sub-
way system in which there was a 75 percent decrease after the guideline
implementation. Despite the role of media on transmissions of suicide, she
cautioned that media reporting on suicide alone does not lead to suicide
contagion; the host, audience, and observer’s preexisting susceptibility all
play a role as well.
Dr. Gould noted that while there is a body of evidence on the relation-
ship between traditional media reporting and suicide contagion, the effects
of the Internet have not been well studied. She suggested that trying to
determine the effects of the Internet on suicide contagion is challenging
because the speed at which the communication is shared is faster than
anything seen before or even envisioned. Dr. Fagan suggested there is a
paradox when it comes to the role of the media and community violence.
From one perspective, the more time a youth spends on the Internet, the
less time he or she is out in the community engaging in violent behavior.
However, youth are exposed to violent content through the Internet. That
raises many other questions about, for example, what the dose-response
curves are and what personal characteristics are mediating factors. Dr.
Watts also commented on the paradox of violence and the Internet. As an
example, she stated that individuals who have leanings toward pedophilia
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PATTERNS OF TRANSMISSION OF VIOLENCE 13
may be in scattered physical locations, but the Internet provides an op-
portunity to link up with like-minded people and to reinforce and condone
those behaviors and maybe lead to action. But she also acknowledged that
the Internet has provided extensive opportunities in terms of promoting
alternatives and providing youth different forms of relationships and ways
to have relationships.
Youth Factors
Several workshop speakers suggested that age can play a role in the
contagion of violence. Dr. Dubow cited that the youngest children within
his studies have been the most impressionable in terms of the exposure
to violence. Additionally, evidence shows that exposure to ethnopolitical
violence adversely affects a child’s emotional security toward his or her
community, which in turn leads to more externalizing behaviors such as ag-
gression and attention disorders (Cummings et al., 2010, 2011). Dr. Gould
noted that suicide clusters occur primarily among teenagers and young
adults in the United States. She commented that one of the hypotheses for
the youth factor is that neurocognitive functioning in adolescence is not
fully developed. Youth decision making and impulsivity might be one rea-
son why young people may be more susceptible to transmissions through
media reporting and other peer and social networks.
Socioeconomic Factors
Dr. Rosenberg noted that one of the increasing interests in global health
and disease prevention is social and economic determinants, possibly even
more so than physiological determinants of health. He suggested this is an
area that holds great potential for contributing to the contagion of violence
model. Dr. Slutkin commented that violence itself is a social and economic
determinant of the other health issues and, arguably, could be the dominant
social and economic determinant of health outcomes. Dr. Fagan added that
the socioeconomic determinants that often are risk factors of violence are
also risk factors for other adverse health outcomes.
IMPLICATIONS FOR INTERVENTION
The evidence supporting the contagion of violence within and across
types of violence has implications for designing interventions to inter-
rupt the contagion. Many speakers commented that, like other infectious
diseases, a reduction in the spread of violence requires interventions that
reduce susceptibility and devise new norms. Several speakers also noted
that interventions designed to prevent the spread of one type of violence
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14 CONTAGION OF VIOLENCE
often have either positive or negative effects on the spread of other types
of violence.
Interventions can be multidirectional. Dr. Watts cited an example of
an intervention in Côte d’Ivoire that was focused on preventing intimate
partner violence by working with men to redefine constructs of mascu-
linity. In follow-up surveys, the data collected suggested that some men
involved in the intervention program chose not to become involved in cur-
rent ethnopolitical violence because of the experience they had during the
intervention program. However, some multidirectional consequences can be
negative. Dr. Fagan told an anecdote of a policing program in New York
that involves stopping individuals to search for illegal guns, increasing the
number of young women carrying guns because they are not stopped and
searched as often as men.
Some speakers suggested that interventions should focus on changing
social norms. Dr. Watts suggested that changing social norms around the
construct of masculinity has been shown to prevent the contagion of fam-
ily violence. She also noted that intervention programs often focus on the
woman who had been a victim of intimate partner violence, but do not
address the children within the household. She suggested that interventions
targeted for the entire household are key to interrupting the contagion of
violence. Dr. Fagan suggested that retooling the relationship between the
police and gun offenders could help interrupt community-level violence.
Unregulated punishment can exacerbate susceptibility to violence and in-
crease the network density of people who share police victimization expe-
riences. Dr. Gould commented that, to interrupt suicide contagion, social
norms regarding talking openly about suicide risks need to change. There
is a myth that because suicide is contagious, you cannot ask about suicide.
However, you can assess for suicidal ideation without making a person
think that he or she should commit suicide.
Dr. Dubow commented on the importance of interventions focused on
protective factors. Most interventions to prevent ethnopolitical violence
are trauma-focused. However, the evidence is showing the importance of
protective factors and such interventions can be implemented in school
and community settings. He also noted the importance of enhancing the
protective factor of the family (specifically, the family is protective against
exposure to violence on children), by bolstering the family itself. This could
be through providing mental health services to families during times of eth-
nopolitical conflict, or in the case of reintegration post-conflict (such in the
case of child soldiers), by providing extra-familial activities such as work
that reduce stress on the family structure itself.
Speaker Carl Bell of the Community Mental Health Council com-
mented that one of the challenges with public health interventions to inter-
rupt epidemics is that the epidemics often are cyclical. He gave the example
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PATTERNS OF TRANSMISSION OF VIOLENCE 15
of a syphilis epidemic in gay men in Chicago: “We put signs on the buses.
The epidemic went away. The signs came down. The epidemic came back.”
He suggested that three things are needed to stop an epidemic: an evidence
base, an implementation system, and political will.
Key Messages Raised by Individual Speakers
• Violence is contagious both within and across types of violence (Dubow, Fagan,
Gould, Huesmann, Slutkin, Watts).
• Social norms contribute to the contagion of violence and norms change has the
potential to interrupt it (Fagan, Gould, Slutkin, Watts).
• Media can both facilitate and prevent the contagion of violence; however, the
role of the Internet in the contagion process is not well understood (Fagan,
Gould, Huesmann, Watts).
• Dose-response effect applies across types of violence (Dubow, Gould, Watts).
• Understanding the contagion process can inform the development of violence
prevention interventions as well as illuminate potential unintended conse-
quences that affect other types of violence (Bell, Fagan, Gould, Watts).
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