Conceptual Basis and Classifications

Oxford Research Encyclopedia of Global Public Health Maria Cecília de Souza Minayo and Saul Franco February, 2018. 26p. DOI: 10.1093/acrefore/9780190632366.013.32

Summary and Keywords Violence is a problem that accompanies the trajectory of humanity, but it presents itself in different ways in each society and throughout its historical development. Despite having different meanings according to the field of knowledge from which it is addressed and the institutions that tackle it, there are some common elements in the definition of this phenomenon. It is acknowledged as the intentional use of force and power by individuals, groups, classes, or countries to impose themselves on others, causing harm and limiting or denying rights. Its most frequent and visible forms include homicides, suicides, war, and terrorism, but violence is also articulated and manifested in less visible forms, such as gender violence, domestic violence, and enforced disappearances. Although attention to the consequences of different forms of violence has always been part of health services, its formal and global inclusion in health sector policies and guidelines is very recent. It was only in 1996 that the World Health Organization acknowledged it as a priority in the health programs of all countries. Violence affects individual and collective health; causes deaths, injuries, and physical and mental trauma; decreases the quality of life; and impairs the well-being of people, communities, and nations. At the same time, violence poses problems for health researchers trying to understand the complexity of its causes, its dynamics, and the different ways of dealing with it. It also poses serious challenges to health systems and services for the care of victims and perpetrators and the formulation of interdisciplinary, multiprofessional, inter-sectoral, and socially articulated confrontation and prevention policies and programs. Keywords: violence, violence and health, health services, health promotion, prevention, human rights

Conceptual Basis and Classifications Violence as a Complex Socio-Historical Phenomenon In its origin and manifestations, violence is a socio-historical phenomenon that accompanies the entire trajectory of humanity. It is manifested in acts performed individually or institutionally by persons, groups, classes, or nations, with the aim of harming, injuring, mutilating, or killing the other. Damage can be physical, economical, psychological, or sexual, and it can be inflicted directly or through neglect. Of Latin origin, the word violence comes from the word vis, which means force and refers to notions of constraint and use of physical superiority. Violent events deal with conflicts of authority, struggles for power, and the will to dominate and annihilate others or their assets. As a social fact, violence has been present since the biblical story of the fratricidal dispute and the killing of Abel by Cain, revealing the historical coexistence of human society with this problem. Its manifestations are approved or disapproved, licit or illicit, depending on the 1

historical time and the cultural norms of different societies (Chesnais, 1981; Domenach, 1981; Franco, 1999; Minayo, 2005, 2013). There are many explanatory theories on the origin of violence. Some scientists interpret it as a phenomenon of an individual and biological order and of a physiological, biochemical, neurological and genetic nature. In this view, metabolic disorders, hormonal differences, or disorders in the regulation of emotions mold individuals prone to lacking control of aggressive behaviors (Raine, 2002; Meyer-Lindenberg et al., 2006; Craig & Halton, 2009; Mendes, Mari, Singer, Barros, & Mello, 2009; Jianghong, 2011). From a psychosocial standpoint, the work of Sigmund Freud (1964, 2002) puts forward various interpretations of violence. In his early writings, the author associates it with the instinctive aggressiveness of the human being. He subsequently defines it as an instrument of conflict arbitration, and therefore a general principle of human action when faced with competitive situations. At an even later stage, which is evident in his correspondence with Einstein (Freud, 1964), he proposes the idea of overcoming violence by building a community of interests. In his view, dialogue and peaceful coexistence through law and the pursuit of the collective good leads people to prefer civilization to the pure and simple imposition of force. For their part, philosophers and scientists throughout history have stressed the prominence of social and political aspects of violence. Some contend that violence is embedded and rooted in social relations, and also dialectically within consciences and subjectivities, permeating all levels of individual and collective life (Domenach, 1981; Franco, 1999; Minayo, 2005, 2013). However, for a number of reasons—and this is a consensus established by UNESCO in 1981 (Domenach, 1981)—no explanation of violence is restricted to a single level. On the contrary, it constitutes a multi-causal phenomenon in which environmental, psychological, social, and biological factors interact. This interrelationship occurs in multiple directions (Mendes et al., 2009). Biological factors serve as a risk, or protective elements and environmental and contextual factors act on biological aspects, with the capacity to compensate for or enhance the negative effects of violent socialization. According to the philosopher Hannah Arendt (1970), the most important aspect of violence is to “dramatize causes,” namely to call attention to the existence of situations and problems of cruelty that end up appearing natural in the culture and relationships between people. Arendt reacts to several thinkers who are complacent about the role of violence in history: against Friedrich Engels (1959), who presents it as an accelerator of economic development; against the naive and simplistic thinking of Frantz Fanon (1963), who considers it a form of revenge of the underprivileged; against Georges Sorel (1972), who defines it as a necessary myth for the change of unequal society in the quest for an egalitarian collectivity; and against Jean-Paul Sartre (1963), who considers it inevitable when the population experiences moments of scarcity and necessity. Arendt (2004) also analyzes Nazism and Stalinism, condemning the expressions of cruelty exposed in totalitarian political experiences.

The Main Characteristics of Contemporary Violence

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Four of the main characteristics of current violence are generalization, diversification, globalization, and increasing complexity. Generalization This refers to the presence of violence in almost all areas of life, at all levels of relationships between people and groups. It refers to a temporal, spatial and relational generalization. Notwithstanding this characteristic, the violence that is documented is merely a minimal part of that which actually occurs. Generalization must be examined critically. On the one hand, one must take into account the role played by the media in giving immediate and sometimes disproportionate importance to certain events and minimizing others. On the other hand, as Chesnais (1981) rightly observed after studying more than 200 years of violence in Europe, sensations are different from facts, and each society gives greater emphasis to certain manifestations and rejects or ignores others. Awareness of violence and its effects is a product of the development of human, social, and political rights and the broadening of citizenship in modern times. Diversification Violence is manifested in many forms. Indeed, multiple typifications can be made according to characteristics, motives, determinants, and circumstances (Galtung, 1998). Moreover, given scientific, technological, and IT developments, the generation of new forms of violence is on the rise. Examples include nuclear weapons, the precision and lethality of certain missiles, cyber-violence (Broadband Commission, 2015), and the application of greater knowledge of the human response to torture and the limits of resistance of the human body to specific forms of torture. Globalization Violence has certainly not escaped globalization (López, 2001). The transnational expansion of the major military, economic, and political powers; the global networks of trafficking in persons, narcotics, and firearms; the presence in many countries of militants and sympathizers of different religions and organizations; and advances in communication technology have created the conditions for certain types of violence—especially terrorism—to become a global threat and continue to escalate exponentially in many countries (Wieviorka, 2006). The globalization of violence implies not only its potential existence in any country—an issue observed throughout history—but also the organization and systematic execution of some of its forms, with common motives, ends, and methods, in any region or country where the interests or values that motivate it are at stake (Alexander, 2015). Furthermore, the advent of social media has given violent acts a level of visibility and immediacy that is unprecedented in human history (Castells, 1996). Increasing Complexity Violence has always been difficult to understand and confront, but the characteristics previously highlighted lend it even greater complexity. Undoubtedly the developments of the so-called social sciences, linked to modernity, have enriched the bases and instruments for 3

dealing with violence (Arendt, 1970; Domenach, 1981; Maffesoli, 1987; Benjamin, 1995). However, the increasing diversity of its forms, motives, actors, and dynamics, and the broad differences in the way it is assumed, interpreted, and confronted in different sociocultural and political contexts make it an increasingly complex problem rooted in multiple interconnected contexts, with changing and sometimes uncertain manifestations and implications. The complexity of violence, rather than discouraging the work of understanding and confronting it, should stimulate intellectual and social efforts to try to understand it and reduce its negative impacts on the lives of people and society.

Violence as a Health Issue Although the deleterious effects of violence have been witnessed since time immemorial, the official legitimation of the subject as a public health issue is recent. It was only at the World Health Assembly in 1996 (World Health Organization [WHO], 1996) that the prevention of violence was raised to the level of a public health priority after the issue had been raised at the Pan American Health Organization (PAHO, 1994), in view of its prevalence in the Americas. Since then, studies and research, official documents, and sectorial action proposals have multiplied internationally (Krug, Mercy, & Zwi, 2002; Dahlberg & Krug, 2006; WHO, 2002a, 2014a, 2005). They acknowledge that violence affects individual and collective health, causes deaths, injuries, and physical and mental trauma; diminishes the quality of life of people and communities; poses new problems for medical care and services; and reveals the need for preventive and management interventions on an interdisciplinary, multi-professional, intersectoral, and socially engaged basis. Violence can be understood, typified, and classified from multiple angles depending on the areas of knowledge or the agencies that try to understand or tackle it. In the field of public health, the acquired scientific and practical knowledge now enables the sector to present two levels of categorization of this topic. The first is typification of its main forms: self-inflicted, interpersonal, and collective. The second is classification of its nature: physical, psychological, and sexual maltreatment; negligence; and economic and asset abuse. Typification • Self-inflicted violence is the leading cause of violent death in the world. It refers to attempted and consummated suicides, to the ideation to end life and deliberately provoke self-harm. • Interpersonal violence is classified as that which occurs in the following relationships: (1) intrafamilial: between intimate partners (conjugal violence) and between family members (between parents and children, between siblings, against grandparents and other persons in the domestic environment) and (2) community: between known and unknown people in the neighborhood and in institutions such as schools, workplaces, prisons, nursing homes, and hospitals. It comes in several forms: adolescent violence, fights, physical assault, rape, sexual assault, bullying, disrespect for the elderly, and manifestation of prejudice, among others. • Collective violence is that which occurs in macro-social, political, and economic spaces and is characterized by the domination of groups, classes, states, or countries. It manifests itself in: 4

(1) invisible and “naturalized” forms in the production and reproduction of prejudices and discriminations, in the denial of essential public services, and in maintaining disadvantages in terms of opportunity for development of the poorest and most underprivileged social strata and (2) visible forms, such as banditry, bloody disputes between gangs and factions, torture, terrorist acts, hate crimes, wars, genocide, and armed conflicts between and within countries, where people and territories are decimated, people are displaced, ecosystems are destroyed, insecurity and loss of hope in the future is engendered, and freedom of expression, disagreement, and manifestation are curtailed. Nature There are five modalities of violence in which the terms abuse or maltreatment are used alternatively: physical, psychological, and sexual violence; neglect or deprivation of care; and economic and financial abuse. • Physical violence involves the use of force leading to death, injury, trauma, pain, or disability in another person. It occurs in all social settings and is the most easily recognized expression of violence. It causes great impact when directed at children and adolescents in the family setting or so-called welfare institutions. Women in the domestic environment and especially men in the community environment are its main victims. In situations of armed conflict and war, physical violence affects the entire population indiscriminately. Violence kills and causes bodily harm, undermines physical and mental health, and has incalculable social, economic, and cultural impacts. Nonetheless, physical maltreatment is usually accepted in many cultures as a strategy for the education of children and means of family control, as an important personal defense mechanism against threats, and as a way to contain or defeat enemy groups in situations of war or armed conflict. • Psychological violence refers to verbal or gestural aggression aimed at terrorizing, rejecting, or humiliating victims; restricting their freedom; or isolating them from social interaction. This type of violence, which may go unrecognized and unreported, has an effect on self-esteem and self-confidence, particularly in the early stages of life, and often produces or is associated with depressive and psychosomatic disorders. • Sexual violence refers to a violent act or interplay in heterosexual or homosexual relationships aimed at sexual arousal or erotic or pornographic practices marked by enticement, inveiglement, or physical violence. Victims of this type of abuse tend to feel guilt, suffer from low self-esteem, have growth and physical and emotional development problems, and are more vulnerable to suicidal ideation and attempts. • Neglect and deprivation of care are characterized by the absence, refusal, or lack of attention to someone who needs protection, support, or care. Neglected children and adolescents are often victims of malnutrition, late school arrival, and a number of risks such as burns, being run over, ingestion of cleaning fluids, and sexual abuse, among others. Neglect and deprivation of care for the elderly population, within both families and institutions, have become increasingly evident. The most vulnerable are the socially, physically, and mentally dependent.

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• Economic and financial abuse is characterized by the improper or unlawful exploitation of the non-consensual use of someone’s monetary or patrimonial resources, by family members, financial institutions, or others. Victims can include expropriated landowners, immigrants, and refugees. One limitation of classifications like these is their schematic character. Expressions of violence do not fit any conventional definitions, as they are more complex than any classification that attempts to encompass them. They interact, some empowering others, provoking physical and emotional harm and illness. The main advantage of categorization is to facilitate the elaboration of policies, programs, and protocols, so that health professionals have standardized instruments for action.

Contemporary Violence and Its Consequences on Social Life and Health Deaths and injuries from attempted homicides and suicides, terrorist acts, rebellions, and acts of war are only the visible parts of violence. Because violence invades all aspects of life, it is difficult and risky to establish a kind of scale for its forms and consequences. There are, however some ways to check the impact on life and health, for example through studies such as the so-called Global Burden of Disease, Injuries, and Risk Factors (GBD). GBD data are derived from country-provided sources such as vital records, verbal autopsies, hospital information, and police records on homicides, accidents, and suicides. These sources are complemented with reporting data from international agencies such as the United Nations Surveys on Crime Trends (United Nations Office on Drugs and Crime [UNODC], 2014). Based on these documents, Haagsma et al. (2016) estimate that there were 4.8 million violence-related deaths worldwide in 2013, including fatalities from traffic accidents and others. Subtracting the latter, according to the World Health Organization (WHO, 2014a), half of the violent deaths occurred by suicide, a third by homicide, and a fifth by wars. The quantification of community and interpersonal violence at the global level is also very difficult as it is a diffuse phenomenon. To estimate it, Haagsma et al. (2016) used integrative modeling that simultaneously produces estimates of incidence, prevalence, and remission by age and sex; with the available data they estimate that in 2013, at least 973 million people suffered some type of health problem resulting from violent causes. The most notable were injuries due to collective violence (69.1%) and interpersonal violence (8.4%). Collective, interpersonal, and community manifestations of violence affect people’s health in daily life and throughout their life cycle. Suicide Suicide is one of the most complex and significant human events. Understanding its motives, risk factors, and levels of determination has preoccupied philosophers, sociologists, theologians, epidemiologists, psychologists, and psychoanalysts for centuries (Durkheim, 2008; Amery, 2005; Bonete, 2004; WHO, 2014b). The act of suicide may be intended to transmit a message to people or institutions, and generally causes feelings of guilt and impotence in the recipients of the message and those close to them. The WHO reported 804,000 cases in 2012, with a rate of 11.4/100,000 (WHO, 2014b). In the wealthiest countries, suicide is responsible 6

for 81% of deaths from violent causes, and in middle- and low-income countries, for 44% of male and 70% of female deaths from violent causes. Women attempt suicide more frequently than men, but men are more successful in their attempts. The current male suicide rate is 15/100,000, against 8/100,000 for females. By age group, people in their 70s are at greater risk in many countries, although globally the rates for elderly males are four times greater than for elderly females. However, the highest number of suicides is recorded among youths and young adults worldwide (WHO, 2014b). The most frequent ways of committing suicide at the global level are the ingestion of pesticides and medications, hanging, use of firearms, and jumping into the void. The order of frequency of these forms varies between cultures, countries, and age groups. The home and other places where daily life occurs are the sites most used by those who commit suicide (WHO, 2014b; Franco et al., 2017). Psycho-emotional disorders are possibly most related to the decision to end life, including depression, affective crises, and problems with social adaptation, impulsivity, or self-esteem. Research has also highlighted suicide’s association with previous violence, particularly sexual violence in childhood and adolescence; with problems related to chronic diseases; and with economic, social, and cultural conditions, such as employment, family dynamics, discrimination, and religious beliefs (Hawton, Simkin, Fagg, & Hawkins, 1995; WHO, 2014b; O’Neill, Ennis, Corry, & Bunting, 2017). Consummated and attempted suicides often inspire other self-inflicted deaths. Homicides If violence is the forced denial of all rights, homicide — being the denial of the fundamental right to life —constitutes the ultimate form of violence. The estimated number of victims in 2012 was approximately 475,000 according to the WHO (WHO, 2014a), coinciding with data from the UNODC study (2014). The average world rate was 6.2/100,000 inhabitants, with very broad variations per country and region. At the continental level, the Americas have the highest rate (36%), followed by Africa (31%), Asia (28%), Europe (5%), and Oceania (0.3%). At the national level, the differences are also very significant. In Singapore in 2012, the rate was 0 and 5/100,000 in Cuba, while in South Africa it reached 33/100,000 and in Honduras, 75/100,000, the highest in the world that year. More than half of the dead were under 30 years old; and 60% were men aged between 15 and 44. Furthermore, 95% of the perpetrators were male, as were 80% of the victims (WHO, 2002a), albeit with differentiations by region. In the Americas 12% of the victims were women, but in Asia that percentage was 29%. The WHO highlights the fact that between 2000 and 2012, estimated homicide rates recorded a decline of more than 16% (WHO, 2014a). Despite this decrease, homicides represent a high social and health burden: they affect the living conditions and family relationships of victims and communities; they change the demographic structure and life expectancy of countries; and they have negative economic consequences, due to the loss of productive people or increased security spending. When the frequency is very high, as is the case in the Americas (Souza, 2012; Souza et al., 2012), homicides cause diffuse social fear, hinder the freedom of movement and expression, affect the health of communities, and are associated with 7

increased inequities and social exclusion. They also raise serious ethical questions about the value of life and compliance with norms of coexistence. Wars and Armed Conflict Deaths from wars and armed conflicts within countries were 130,000 in 2014, according to data from the UPPSALA Department of Peace and Conflict Studies (Pettersson & Wallensteen, 2015; Melander, Pettersson, & Theerner, 2016). Violence resulting from these phenomena is responsible for devastation in social organizations, economies, and public order, and the human and financial cost of humanitarian services. The consequences are incalculable because of displacement and forced migration, disappearance of individuals, separation of family members, deprivations of all kinds, hunger, malnutrition, and other effects on human dignity (Sirinivasa & Lakshminarayana, 2006; Santa Bárbara, 2006; Franco, Suarez, Naranjo, Báez, & Rozo, 2006; Justino, 2011). In virtually all of the war scenarios and internal armed conflicts, adult women, adolescents, and children are used as barter, enslaved, or killed (Abramsky et al., 2011; Garcia-Moreno, Heise, Jansen, Ellsberg, & Watts, 2005). In these situations, the health sector experiences its own drama, because injuries, trauma, and illness increase, but the civilian population is often subject to restrictions on access to health care and the distribution of medication (WHO, 2002a, 2014a). Both international humanitarian rights and the medical mission are frequently violated in war situations. Migration and Forced Displacement Forced displacement is at the same time a consequence of violence and one of the cruelest forms of its manifestation. Voluntary migration is a human right enshrined in the Universal Declaration of Human Rights, but those who are forced to migrate outside or within their country because of ideological or political persecution or because they are in the crossfire of a war face serious consequences, as do those around them (Franco et al., 2006; Melander, Pettersson, & Themnér, 2016). The 5,079 forced migrants who lost their lives in 2016 trying to cross the Mediterranean into Europe are just the tip of the iceberg of an old problem that has taken on new strength. According to the Office of the United Nations High Commissioner for Refugees (UNHCR), by the end of 2015, 65.3 million internally displaced persons (IDPs) were recorded in the world, the highest figure since World War II and four times the total of a decade earlier (UNHCR, 2016). Of these, 40.8 million are displaced within their own countries, 21.3 million are refugees, and 3.2 million are asylum seekers. It is estimated that 51% of the refugees are children. Inequities, intolerance, war, poverty, and political or religious persecution continue to be the main causes of forced displacement. The consequences include expropriation of land and fundamental goods, loss of environmental and cultural references, rupture of family and social networks, and exposure to serious security risks, malnutrition, overcrowding, and physical and mental illnesses, including death (National Center for Historical Memory, 2013). That is why forced displacement is considered a crime against humanity, and there are serious indications that it will continue to increase in the coming years. Terrorism

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Terrorism is one of the most feared and recognized forms of violence today (Phillips, 2015). But there is a lack of definition of the concept, which is due to political rather than semantic or legal problems. The involvement of states and the potential disqualification of some insurgent organizations and movements, as per the assumed definition of a “terrorist,” have meant that neither international organizations nor the political forces confronted globally or within some countries have been able to reach complete agreement on what constitutes terrorism (Torres, 2010). The lack of an official definition does not imply that there is no agreement on the subject. It is generally accepted that terrorism is the illegal use of force against persons or objects by members of organizations that seek predominantly political, economic, and cultural objectives through the intimidation of individuals and society. It is also accepted that surprise, audacity, strong emotional impact, and mediatic and symbolic potential are important parts of terrorist acts. There is a mixture of selective and indiscriminate choice of victims. So far this century, the most emblematic terrorist act has been the attack on the World Trade Center towers in New York, on September 11, 2001, with an estimated 3,000 dead and 6,000 injured. Since then there has been greater awareness of the problem and greater presence in the media and in the political and academic spheres (Martini, 2015). Attacks on or against means of transport; attacks on religious, cultural, or entertainment centers; public beheading of suspected enemies; massive abduction of girls; and attacks with gas cylinders and other explosive devices on entire populations are part of this terrorist escalation in countries throughout the world. The response of the states involved has had components that fit within the concept of terrorism and, specifically, of state terrorism. Use of the adjective “terrorist” from the state and its power to fight insurgencies have been tolerated, but the same are avoided or censured in the opposite direction. As long as terrorism is not recognized in both directions and agreements and limits are not established, a more precise concept and definition will not be reached, nor will the world be able to tackle in depth what for some is the phantom that threatens the 21st century. Gender Violence There are multiple forms of gender violence, with three main types—sexual, physical, and psychological—occurring among men, women, the LGBTQ population, as well as young people and the elderly. It is also present in other expressions of violence. Although it is a very old and deep-rooted reality, the “gender” category is relatively new, so its specific classification and typification are in the process of consolidation. As this form of violence typically occurs in the family and private spheres, it is difficult to denounce and report, such that known figures are still far lower than the true figures. Studies on gender violence reveal a peculiarity: men form the group that kills more and dies more from homicide, traffic and work accidents, and suicide, at any stage of their life cycle. Men also suffer the most injuries and traumas, many of them incapacitating, and therefore men are hospitalized more and need more rehabilitation services (WHO, 2002a; Haagsma et al., 2016). These kinds of grievances are linked to a macho culture of excessive exposure to 9

risk, bellicosity, disproportionate use of aggressiveness, and thirst for power. Although at a lower scale in relation to women, the frequency and severity of sexual abuse of children and adolescents (Lowerkron, 2010) should be noted, especially that perpetrated by close relatives, teachers, priests, and in-person or cybernetic sexual exploiters. Violence against women is a typical problem of the patriarchalism that prevails in the world despite all the movements to overcome it. It is estimated that, globally, one in three women suffers some form of gender-based violence in the course of their lives (WHO, 2005; UNFPA, 2014). Sex selectivity in some countries means that female fetuses may be aborted. In the neonatal period, in some countries, girls may be subject to negligence and infanticide. In childhood, they often suffer sexual, physical, and psychological abuse more than boys. In adolescence and adulthood, many are forced into prostitution and fall victim to trafficking, harassment, and sexual abuse, including rape. And more than men, in old age they continue to suffer various forms of violence, in addition to those associated with their status as an elderly person (Garcia-Moreno et al., 2005; Ellsberg, Jansen, Heise, Watts, & Garcia-Moreno, 2008; Abramsky et al., 2011). Much of the violence against women takes place in marital or other intimate relationships, and the companions and ex-companions are the main aggressors. The majority of the victims are between 20 and 44 years old (WHO, 2005, 2014a; Ariza, 2012). Gender-based murder— femicide—is the culmination of all forms of violence against women. The estimated annual number of femicides in the world is 65,000, equivalent to approximately 180 women killed each day, of which 12 are Latin American (ONU-ECLAC, 2016). Although aggressions and mistreatment against women can lead to death, their most frequent effects are non-fatal (Garcia-Moreno et al., 2005; Ellsberg et al., 2008; Abramsky et al., 2011; WHO, 2014a). Several studies describe the results of such violence, including permanent lesions; problems such as headache, abdominal pain, lower back pain, bleeding, or vaginal discharge becoming chronic; genital lesions and pain during sexual intercourse; sleep and eating disorders; unhealthy behaviors such as smoking, unsafe sex, abusing alcohol and other drugs; transmission of sexually transmitted diseases; complications in pregnancy; spontaneous and induced abortion; and infertility. Victims of child abuse are also more likely to have babies with low birthweight, who are premature, malnourished, susceptible to infection in the first year of life, and more vulnerable to child mortality. Members of the LGBTQ population, a group seeking to affirm or reaffirm its rights, are often victims of violence inflicted on the basis of sexual orientation. Often, religious or extremist ideologies underlie aggression manifested through discrimination, threats, psychological and physical abuse including murder, blackmail, and extortion, and sexual abuse and rape. The main victims are males: gays, transvestites, transsexuals, and bisexuals, between 15 and 30 years of age. Most violations occur at home, on the streets, at workplaces, in schools, or in churches (Albuquerque et al., 2016; Bine, 2017). Among the factors associated with gender violence that lead to illness in this population are psychological distress; daily life marked by anxiety, fear, rejection, depression, feelings of guilt, insecurity, shame, and social isolation; and difficulties in establishing and maintaining stable relationships. Violence Against Children and Adolescents 10

Two major types of violence have a particular impact on the lives of children and adolescents: that which happens in the family and that which happens in the community where they live. Despite the recognition of the human rights of children, violence is perceived by many parents in various parts of the world as an educational strategy. Society accepts and legitimizes aggression, facilitating its perpetuation in customs, in forms of family organization, and in styles of supervision and care (Markowitz, 2001). Parents are responsible for the primary relationships that constitute the mainstays of subjective construction (Jianghong, 2011; Straus, 2009). Some factors facilitate the occurrence of family violence, such as the existence of conflicts not resolved by dialogue and some demographic and socioeconomic characteristics such as low maternal schooling, low family socioeconomic level, presence of many children in the same house, being male, belonging to racial and ethnic minority groups, and experiencing difficulties of adaptation or lack of support in urban centers. Prematurity, congenital malformations, and physical and mental disabilities are also among the facilitating factors of victimization by parents and caregivers (Assis & Avanci, 2004; Centers for Disease Control and Prevention [CDC], 2008). At this stage where the comprehension of cultural norms is at stake, physical, psychological, sexual, and negligent maltreatment can have immediate or medium- and long-term consequences. The immediate effects are more easily identifiable: cranial lesions, dislocations, excoriations, bruises, cuts, burns, and ruptures of organs. Many of them require hospitalization or lead to death. Damages can occur during gestation, causing prematurity and impairing a child’s physical, psychosocial, and cognitive development with lifelong repercussions (Markowitz, 2001; UNICEF, 2006). The consequences of sexual violence, are traumatic and can lead to increased aggression, depression, and suicidal behavior. And negligence is responsible for falls, poisoning, intoxication, burns, pedestrian accidents near the home, and increasing the likelihood of suffering from immuno-preventable diseases. Inadequate hygienic habits increase the risk of diarrheal, dermatological, and oral diseases and failure to complete medical prescriptions (Assis & Avanci, 2004). Children’s coexistence with community violence also has an impact on their quality of life and health (Garbarino, Dubrow, Kostelny, & Pardo, 1992). Those living in areas with high and chronic rates of social conflict may become more insensitive and see violence as a norm of social interaction (Assis & Avanci, 2004). These consequences occur regardless of whether the violence takes place in a troubled area or in a war situation. A violent environment is associated with poor performance in school, behavioral problems such as depression and lack of control of aggression, and permanent fear. This situation is more prevalent in areas of lower purchasing power where the institutional resources of the health and education sector are deficient, informality prevails, and public security is lacking (Buka, Stichick, Birdthistle, & Earls, 2001). For some, the violence they witness or participate in can act as an acculturation and gateway into the world of crime. Children and youths who drop out of school and join gangs are often distant from health care, are victims of the authoritarianism of gang leaders, and are subjected to aggression that leads to premature death (Rosario, Salzinger, Feldman, & Ng-Mak, 2003; UNDP, 2009).

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The majority of scholars, including Assis and Avanci (2004) and Straus (2009), emphasize that the various forms of violence occurring in the family and in the community hinder the growth and physical and emotional development of boys and girls. Moreover, those who experience or witness abuse or maltreatment are more likely than other children to perpetuate such violence in the future (Brookmeyer, Henrich, & Schwab-Stone, 2005). The experience called revictimization or entanglement in the cycle of violence usually generates an acculturation that naturalizes the abuse and maltreatment in the course of life. Several authors, including Rosario et al. (2003), Santa Barbara (2006), and Assis, Pesce, and Avanci (2006), affirm, however, that the consequences of living in an aggressive environment are affected by not only the nature and gravity of the experience, but also the capacity of these young people to perceive and assess the situation and seek support to protect themselves. Violence Against the Elderly Maltreatment of the elderly is now an important issue for society and for the health sector, given the increase in life expectancy in most countries. Not even in this final stage of the life cycle are individuals free of all types of violence. Burston (1975), WHO (2002b), and Stavrianos, Vasiliadis, Emmanouil, Pantelidou, and Pantaziz (2011) note that the abuse mainly occurs in interpersonal and community life (90%) and has consequences of a physical and emotional nature. Violence against the elderly can leave marks like abrasions, skin wounds, bruises, burns, unexplained falls, fractures, and organ rupture. Emotional abuse and neglect are more common than violence that leaves physical marks, however. This may manifest as lack of appetite, dehydration, weight loss, malnutrition, insomnia, feelings of fear and anxiety, irritability, hopelessness, guilt, sadness, and suicidal behavior. Population-based qualitative research (WHO, 2002b; Moraes, Apratto Júnior, & Reichenheim, 2008; Sanches, 2006) indicates that the elderly who suffer most from violence are physically, emotionally and economically dependent, and those with depression, urinary and fecal incontinence, diabetes, or rheumatism and comorbidities. In essence, the currently consolidated studies make it possible to say that: (1) all the consequences, whether of collective violence or of community or interpersonal violence, are manifested in the individuals through physical and emotional injuries. The consequences occur in a differentiated way, depending on how the individuals represent their culture and deal with their subjective needs, their biological heritage, and their health conditions. (2) Risks and all sorts of adversities are present in the life of any human being. However, there are more damaging events such as wars and natural catastrophes and forced displacements in which social conflicts and indifference, and institutional neglect, are observed. (3) Physical, psychological, or sexual abuse and neglect, family conflicts and separations, and instability in access to goods that meet basic needs lead to harmful consequences for health. (4) A conjunction of factors may increase the possibility of the consequences of violence on individual health. These include the age group of the abuse victim, the types and frequency of abuse, the identity of the aggressor, and the lack of social support in the family and community context. (5) Persons in a repeat or chronic abuse situation often develop symptoms of physical and mental illness. (6) Victims of violence often find it difficult to seek attention for their health or safety, especially when the perpetrator is someone they know and with whom they have an established relationship. 12

Understanding and Confronting Violence From a Health Perspective Health systems have difficulty dealing with problems of violence for multiple reasons. First of all, the biomedical mentality believes that this subject belongs to the sphere of justice and the police. Consequently, health professionals have conceptual deficiencies on a subject that requires interdisciplinary vision and action. Despite frequent recommendations from the World Health Organization (WHO, 1996, 2002a, 2014a), the issue is only slowly entering the agenda of the sector (Minayo, 2006). Thus, professional practices are largely confined to healing the most visible wounds, injuries, or traumas. Professionals who work in the most war-torn places or where armed criminal gangs are present coexist with violence, and their behavior is often hampered by fear, threats, or other restrictions. Difficulties are mainly reported for providing vaccinations, removing patients who need an ambulance, providing care for the elderly, and carrying out health promotion programs, among others. The health sector can also contribute to an increase rather than a reduction in violence. For example, the absence or inefficiency of services in poorer locations is another factor that exacerbates the dissatisfaction of families with their living conditions, generating interpersonal conflicts due to the lack of care and competition among those in need of care. The more debilitated health of children and adolescents without medical assistance also leads to the loss of their parents’ working days, reducing the financial support that sustains the poorest households. The stress caused by suffering with disease and worsening of living conditions contributes to an increase in conflicts in the family and in the vicinity. From the standpoint of confronting violence within the health field, there are at least three basic areas that have or can play a fundamental role: provision of services, public health, and public policy. Health Services in the Face of Violence In health services violence is usually seen in its individual expression, in the injury that it is inflicted on the body and harm to the mental health of people. The rationale is predominantly bionatural and psycho-emotional. The focus is on the consequences of the violent act on the organic and emotional functioning; trying to understand the type and severity of the alterations, their mechanisms, and consequences; and the possibilities of control and recovery of physical and emotional normality. From this medical perspective, the organization and operation of health services need to be structured to care for the victims of violent acts. The most frequent confluence points between violence and health are the emergency services. It is where the wounded and the most serious victims of the various forms of maltreatment, especially physical abuse, converge. This demands multiple resources and qualified personnel, and an adequate network of services that includes immediate attention where the deeds occur, adequate transport to emergency care centers, and timely remission between the different levels of complexity of such centers and subsequent rehabilitation. It should be noted that in countries with high levels of violence there has been a shift in attention from other important but chronic health problems due to the pressure of 13

emergencies generated by violence (Franco, Suarez, Naranjo, Báez, & Rozo, 2006). Also, the high personnel costs and the supplies required by the emergency services that tackle violence call for significant disbursements of funds from both victims and health systems (Jaitman, Soares, Olavarría-Gambi, & Guerrero, 2015). A second confluence point is the hospitals or outpatient medical and psychiatric consultation services, both general and specialized. It is where the victims of bloodless violence, children, women, and the elderly, whose abuse has not generated extreme situations or produced effects requiring emergency care, converge. Possibly the most requested types of care are pediatric, gynecological, and psychiatric services, given the frequency of child abuse, violence against women, and the psycho-emotional effects of different forms of violence. In addition to the access and cost problems of this type of care, the issue of the competence of various medical staff to detect and respond to these types of violence is also important, along with the predominance of ongoing care by a single professional, given that many of these cases require multi-professional teams for their proper management.

Public Health in the Face of Violence There is already a consensus that violence is also a public health problem because of the number of people who die from violent causes or who suffer injuries and serious health afflictions linked to violence. Violence also worsens the quality of life and well-being of millions of people, and places heavy demands of knowledge and action on the health sector. Within public health, epidemiology has applied itself to quantifying the morbidity and mortality caused by violence; recognizing its spatio-temporal distribution, affected gender and age groups, and trends; and understanding the factors that contribute to violence and provide input for the formulation of violence prevention programs (Concha & Guerrero, 1999). By integrating the qualitative approach and methods, epidemiology has acquired a clearer understanding of both the nature and causes of violence, as well as its significance and impact on personal and collective life. The prevention of violence has been one of the priorities of national and international health agencies. Today, proposals, programs, and even manuals for the prevention of suicide, domestic violence, violence against women, children, youth, and the elderly are available (Thornton, Craft, Dahlberg, Lynch, & Baer, 2000). Such programs and materials often focus on aspects related to individual behavior, emotional and cultural components, and the most immediate relationships in family, school, and work environments. Addressing other forms of violence, such as torture, homicide, disappearance, forced displacement, and kidnapping, which involve complex historical, social, and political dimensions, requires changes in the political dynamic, the relationship between societies and states, the collective prioritization of values, and the legal system. It was from the mid-18th century onward that, first in Europe (Rosen, 1985) and later in Latin America (Almeida & Silva, 1999), a theory was developed to acknowledge the historical, social, and political dimensions of health and disease, with deep theoretical-interpretative but also 14

practical implications. This movement, recognized as social medicine and, with some differences, as collective health, has also contributed to the study of violence (Iriart, Waitzkin, Breilh, Estrada, & Merhy, 2002). Its contributions, albeit incipient, aim to give greater attention to the methods of the social and human sciences in the approach to the subject; to study the complexity of its nature and dynamics in depth; and to examine multidisciplinary and politicalsocial, inter-institutional, and, in many cases international, approaches to tackling certain forms of violence.

Health Policies in the Face of Violence The inclusion of violence as the theme and object of health policies is recent. It was only at the end of the last century that the World Health Organization explicitly acknowledged violence as a growing public health problem, although it has been the subject of concern and analysis for some health-care workers since World War II. The impact of wars and some specific forms of violence on mental health and violence against children and women were among the first issues explored. Today, health policies addressing the issue of violence seek to strengthen preventive attitudes and practices, adapt services to the timely and effective care of victims, and base specific programs in areas such as mental health, migrant care, displaced persons and refugees, and the health of women, children, and the elderly. Some focus on particular forms of violence, such as suicide, sexual violence, or school violence (WHO, 2005, 2002a, 2014a, 2014b). The idea of health promotion, which was introduced in the middle of the past century but only developed after the 1980s, has sought to address violence through the investment in values such as the dignity of human life, respect for human rights, coexistence, equity, and solidarity. In times of war, the health sector has defended international humanitarian law and the medical mMission, as well as the recognition of health as a point of convergence between opposing forces and, therefore, as a bridge to peace. This two-way relationship between health and peace is an important point of reflection and discussion today, with great potential for transformation in the ever-changing field of violence and health. Finally, although it does not refer directly to the issue of health and violence is not a central theme, it is necessary to emphasize the importance of the so-called 2030 Agenda (UN, 2015), whereby 193 UN member states commit to goals and targets that seek to transcend structural factors that make the world unequal, exclusionary, and violent. In its preamble, it states: “We are determined to foster peaceful, just and inclusive societies which are free from fear and violence. There can be no sustainable development without peace and no peace without sustainable development.” While the entire Agenda is a statement for peace and quality of life, Sustainable Development Goal (SDG) 16 specifies the underlying factors of violence, such as insecurity, injustice, inequality, corruption, poor governance, illicit financial flows, and the international firearms trade. And there are targets to be met in relation to this diagnosis, with an emphasis on equal access to justice, respect for human rights, the rule of law, and good governance at all levels and “on transparent, effective and accountable institutions” by 2030. These goals are in addition to those of SDG 3, which hope to ensure and promote well-being for all at all ages by 15

reducing premature deaths from accidents and violence by acting on the factors with which they are associated. The 2030 Agenda signatories also redoubled efforts to resolve or prevent conflict and to support post-conflict countries by ensuring that women have a role in peacebuilding. The 2030 Agenda came into effect on January 1, 2016, and it is still too early to assess its effectiveness. The Millennium Development Goals (2000–2015) evaluation report, which preceded it, shows that progress has been made on the sustainability agenda in several countries but not in others, highlighting the difficulties faced by this type of global objective. What can be established today is the existence of a global, national, and regional agenda for action that reflects the awareness of 193 countries regarding the need to transform the world into a safer and less violent place, and the health sector has unequivocal importance in this construction.

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