Family violence permeates our society. It affects us as individuals, family physicians, parents, spouses, educators and citizens. The breadth of the problem is staggering. Public health officials identify family violence as a public health issue of epidemic proportions.1
Domestic violence occurs in one in four American families. In the United States, 2 to 4 million women are abused by an intimate partner each year.2 Of those, 2,000 to 4,000 die of their injuries. Several studies have reported that, regardless of the initial complaint, 22 to 35 percent of women presenting to emergency departments are there for problems related to domestic violence.3-8 One in three female trauma patients is a victim of abuse. Women in the United States are more likely to be assaulted, injured, raped or killed by a current or previous male partner than by assailants of all other categories combined.9 Given that, statistics concerning assaults against women in general are indirect indicators of the degree to which domestic violence permeates our society. It has been reported that 20 percent of adult women, 15 percent of college-age women and 12 percent of adolescent girls have experienced sexual or physical assault in their lifetimes.2 However, the available data underestimate the magnitude of the problem because many cases of assault and domestic violence are not reported. For instance, the Federal Bureau of Investigations (FBI) estimates that less than 37 percent of rapes are actually reported, with the U.S. Department of Justice estimating that only 26 percent are reported. In 1996, the FBI reported 72 per 100,000 women were raped that year, and the National Victim Center estimated that 1.1 million rapes occurred in 1992.
Violence toward children and adolescents is especially disturbing. In 1996, the U.S. Department of Health and Human Services (HHS) and the National Committee to Prevent Child Abuse reported the investigation of more than 3 million reports of child abuse by child protective services agencies. Almost 1 million of these cases were substantiated, reflecting an 18 percent increase since 1990. The same HHS report estimates that each year more than 300,000 children are sexually abused and approximately 1,077 child fatalities occur from maltreatment or abuse.10,11 In 1990, 208,000 crimes against adolescents were reported as child abuse; this is thought to be a low estimate because adolescent abuse is less likely than child abuse to be reported to child protective service agencies.12 And enough crimes are committed against adolescents annually to make this under-reporting a potentially significant factor. In 1992, the Office of Juvenile Justice and Delinquency Prevention reported that an estimated 1.55 million crimes had been committed against adolescents 12 to 17 years of age.13 In addition, the impact of witnessing violence is profound. Between 3.3 and 10 million children witness domestic violence each year, and 50 to 70 percent of the mothers of abused children are themselves abused.14,15
The National Center on Elder Abuse (1996) estimates that 1 to 2 million elderly persons experience abuse and/or neglect. The center also estimates that elderly women make up 58 percent of victims and that approximately two thirds of perpetrators are family members.16
Traditionally, family violence has been considered a private matter. Only in the past 20 years have state and federal officials dealt with domestic violence through the justice system, with punishment and incarceration. Violence has now become a widespread social problem. Violence is also a medical problem, resulting in physical injury, as well as emotional and psychologic harm such as substance abuse, depression, suicide, anxiety, somatizing disorders, eating disorders and chronic pain.17
In addition to its substantial human cost, family violence consumes government and health care dollars. In 1990, the U.S. Department of Justice estimated the aggregate cost of domestic violence to be $67 billion per year, with losses due to child abuse exceeding $164 billion per year. Reports indicate that family violence accounts for at least 21,000 hospitalizations, 99,800 hospital days, 28,700 emergency department visits and 39,000 physician visits each year.10 The family violence program at Rush-Presbyterian Hospital in Chicago reported that, in one year, 708 patients were treated as acute victims of family violence generating charges equal to $1,156,408, or $1,633 per patient.18
Family violence can be defined as the intentional intimidation or abuse of children, adults or elders by a family member, intimate partner or caretaker to gain power and control over the victim.10 Abuse has many forms, including physical and sexual assault, emotional or psychologic mistreatment, threats and intimidation, economic abuse and violation of individual rights:
Violent behavior derives from many sources. Biology can contribute in the form of mental illness in perpetrators and victims. The environment in which children are raised plays a role. Children who grow up in violent homes are more likely to become victims or perpetrators of family violence in adulthood.19,20
The presence of violence or neglect in one's family, the lack of effective parenting by caregivers, the prevalence of violence in society and the media, and the absence of positive role models to demonstrate and teach nonviolent conflict resolution can all contribute to a predisposition to violence. Gender and unequal power are factors in family violence as well. The overwhelming majority of physical domestic violence involves aggressive, assaultive behaviors by men toward women.
Family violence crosses all socioeconomic lines and can affect anyone regardless of race, age, culture or sexual orientation.21 However, the societal ills of poverty and community violence may also play a role in the spreading of the epidemic of violence--and the effects of that epidemic are visible throughout society:
At the University of Maryland, a study of 168 teenagers attending an inner-city clinic reported that 24 percent of those questioned had witnessed a murder and 72 percent knew someone who had been shot. In Los Angeles, it has been estimated that children witness 10 to 20 percent of homicides.28 Although most studies have involved inner-city children, it is clear that suburban and rural children also are witnessing violence in their homes, schools and communities. Fifty-seven percent of sixth-graders from a suburban Pennsylvania school had witnessed some form of violent crime.27
These statistics give a clear picture of the size of the problem, but they may not connect it clearly enough with the practices of family physicians. Family violence will affect at least one third of the patients cared for by family physicians, and the impact of family violence may become evident in the one-on-one relationship of the family physician and the patient. It is imperative that physicians be aware of the prevalence of violence in all sectors of society and be alert for its effects in their encounters with virtually every patient.
Violence against women will be the form of family violence most frequently seen in family medicine. Physicians need to recognize that women who are victims of domestic violence will be patients in every family medicine practice in this country because one in every four women has been a victim of domestic violence at some point in her life, and one in seven women has been victimized in the past year.29 Pregnancy confers no protection. In fact, abuse often begins or escalates during pregnancy. One in six pregnant women is abused during pregnancy and 17 percent of physical or sexual abuse of women occurs during pregnancy.30,31 One study31 reported abuse in 37 percent of obstetric patients and showed that class, race and educational level made no difference.
Domestic violence is not only directed by men toward women. In less than 5 percent of cases, women do assault male partners. Studies have shown that 12 percent of murdered men are killed by their wives or girlfriends. Most of these cases involve women defending themselves in violent relationships. Twenty-four percent of students in one survey reported that they had seen their mothers physically assault their fathers.32
Domestic violence occurs in same-sex relationships at about the same rate as in heterosexual relationships. Between 22 and 46 percent of all gays and lesbians report having been in a physically violent same-sex relationship. Batterers in same-sex relationships may use societal homophobia as a weapon. It may be easier for victims to stay in an abusive relationship than be "found out" by parents or coworkers.33,34
Family physicians see children for well-child care and sick visits and provide much of the adolescent health care in this country. Therefore, family physicians need to recognize that all young patients are at risk for violence, abuse and neglect.
In 1988, a study of elder abuse conducted in the Boston metropolitan area indicated 32 cases per 1,000 older adults.35 The national prevalence of elder abuse is thought to be 2 to 5 percent. Again, this number may be falsely low as many cases are not reported and older persons are frequently socially isolated, making abuse or neglect less likely to be detected.36 Given the number of elderly patients cared for by family physicians, there is a good chance that the typical family physician sees several patients a year who are victims of elder abuse.
Given the statistics discussed, there is no doubt that all family physicians see victims of violence, abuse and neglect regularly as they care for men, women and children of all ages, races, sexual orientations, socioeconomic, ethnic and cultural backgrounds. But, do they recognize the effects of family violence as often as would be desirable? The data are not encouraging.
Despite the large number of battered women seeking medical care for problems related to battering, it has been estimated that health care professionals correctly diagnose only one in 35 cases.21
Fewer than 15 percent of female patients report being asked about violence or abuse by health care professionals.37-39 This occurs despite several studies indicating that women would disclose abuse to their health care professional if asked directly.39,40 A recent study of how primary care physicians screen for intimate-partner abuse and how they intervene when they identify abuse reported that an estimated 10 percent of physicians routinely screen for domestic violence during new-patient visits and 9 percent screen during periodic visits. Where patients presented with physical injuries from abuse, only 79 percent of physicians asked patients direct questions about domestic violence. Seventeen percent of obstetrician-gynecologists routinely screen, compared with 10 percent of family physicians and 6 percent of internists.38 Despite of training and an increased awareness of this national epidemic, family physicians are missing many opportunities to identify and intervene in cases of family violence.
Many barriers impede the recognition of problems with violence in patients and their families. Several myths about family violence exist: the misconception that victims are poor, inner-city women and children; the belief that violence is rare or does not occur in families that seem normal; the feeling that family violence is a private matter; and the notion that victims are in some way responsible for their own abuse. For example, contrary to the classic concept that child abuse is a poor, inner-city epidemic, adolescent abuse is more likely to occur when a child's parents have an above average income and educational level. These parents are even less likely to have a history of abuse by their own parents.41
Identified barriers to screening in primary care practices include the patients' fear of retaliation from an abusive partner, the patients' lack of disclosure during history-taking, the patients' fear of police involvement and cultural differences.38 In addition, the subject of family violence may be too uncomfortable in the physician's own life because 12 to 15 percent of physicians have witnessed domestic violence in their childhood or experienced physical abuse by an intimate partner at some point in their lives.38
Physicians may be reluctant to discuss domestic violence with patients for fear of getting overly involved in personal issues. They may feel they do not have enough time to deal with the issue. Physician concerns about screening for domestic violence include a lack of comfort with the subject, a fear of offending a patient, a sense of powerlessness or loss of control, and insufficient time or knowledge to appropriately or fully address the problem.42
Another barrier, and perhaps the most amendable, is insufficient training in working with victims of domestic violence.41 Not only may the physician lack experience or expertise in screening for abuse but there may also be a lack of knowledge of community resources available for collaboration to address this major public health threat.
Despite barriers to the diagnosis and treatment of victims of family violence, family physicians are in an ideal position to take on this challenge and are compelled to do so by the sheer magnitude of the problem. Family physicians are better able to identify those at risk because they are trained to care for the whole family and for the individual as a part of the larger community. Because of the continuity of care family physicians provide, they can gain patient confidence over time and can serve as sympathetic listeners and patient advocates. Family physicians can provide early intervention to break the cycle of violence through routine screening and the identification of abuse. They can help by teaching parenting skills and counseling patients on the stress of caring for children or elderly parents. Physicians can talk with women and men about their experiences of previous abuse and can be a central referral source for other resources in the community.
Among activities for the American Academy of Family Physicians (AAFP) to consider are the following:
All women, men and children are at risk for family violence. Abuse is a common and complex public health issue that requires the attention of family physicians dedicated to improving the health of this nation's families. Family physicians have a unique opportunity to help break the cycle of violence by working with families to prevent abuse. To do this, physicians can teach parenting and conflict resolution skills that promote respectful and peaceful personal relationships. Ultimately, by working in collaboration with others in the community, the family physician can help accomplish social change. So, too, can the AAFP by continuing its leadership role in organized medicine as it supports and trains its members in ways to effectively address the epidemic of family violence in America.
(1994) (2011 COD)
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Violence (Position Paper)