Violence (Position Paper)
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
Background and Context
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:
- Physical violence refers to rape, battering, assault and neglect. Battering includes hitting, punching, slapping, pushing, kicking and choking. The definition of rape in most states is "the nonconsensual sexual penetration of an adolescent or adult (female or male) obtained by physical force, by threat of bodily harm or when the victim is incapable of giving consent by virtue of mental illness, mental retardation or intoxication."2
- Psychologic or emotional abuse is not as easily identified. It includes shouting, insulting or berating, demeaning language or treatment, controlling or threatening behaviors, isolation, sleep deprivation, stalking, harassment and the destruction of personal property. Emotional abuse can also include constant or recurring exposure of the victim to violence, dysfunctional behavior or substance abuse in the home. Psychologic abuse often reflects the pattern of assaultive and controlling behaviors inherent in violent domestic relationships.
- Economic abuse can include the misuse, withholding or theft of funds by a guardian, refusal to pay child support or not allowing a victim to work or have access to household money. The primary victims of economic abuse are older persons and those less able to manage their financial affairs, such as mentally challenged individuals. Many women in domestic violence relationships suffer economic abuse as well.
- Violation of individual rights can include isolation of a victim from friends or family, denial of access to medical care or the refusal of a caregiver to provide adequate nutrition or shelter. The victim may be of any age group and either gender.
Origins of Violent Behavior
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:
- Television. The American media portray family and community violence as commonplace, if not normative. There is growing concern regarding the impact the media may have on the spread of violent behavior in the United States. One report estimates that a child who was two years old in 1993 will have witnessed 7,000 murders on television by seven years of age. That same child will have been exposed to 100,000 televised acts of interpersonal violence by high school graduation.9 This repeated exposure to violence desensitizes the viewer to the seriousness of the problem because the pain and other effects of violence are minimized or not shown.
- Firearm violence. Many believe that the prevalence of firearms in American society increases the risk of deadliness in family and community violence. It is estimated that 200 million firearms are owned by private citizens in the United States.22 Assaults involving firearms are three times more likely to result in death than those with knives and 23 times more likely to result in death than assaults with other weapons.23 Household members are 18 times more likely to be injured or killed by firearms kept in the home than are intruders.24
- School violence. Weapons in school also have become more prevalent, as devastatingly exhibited by recent school shootings. A national survey conducted in 1990 found that 4.1 percent of students reported carrying a firearm to school. By 1995, that number had increased to 7.6 percent.13 A study in Seattle public schools, which included 50 percent of the district's 11th grade students, revealed that 6 percent of students had carried a handgun to school on at least one occasion.25 A similar study in Illinois indicated that one third of students had taken weapons to school.26 In the Seattle study, 34 percent of students reported they had easy access to handguns and 6.4 percent reported that they owned guns. Of the handgun owners, 33 percent reported that they had fired at someone. Almost 10 percent of the female students reported that firearms had been used in homicides or suicides of family members or close friends.25
- Adolescent violence. The data on violence among adolescents are devastating. In 1994, the FBI reported that 11 percent of all homicide victims were younger than 18 years and that almost one half of these victims were 15 to 17 years of age. The risk of death from interpersonal violence is greater for male than for female adolescents and greater for black males than for any other racial group. The homicide rate for black males between 15 and 19 years of age increased 293 percent, from 45.9 per 100,000 in 1985 to 134.6 per 100,000 in 1994. This is eight times the rate of homicide for white males of the same age group.13 In 70 percent of these cases, victims were murdered with a handgun. Homicide by gunshot is the leading cause of death for black and white males 14 to 17 years of age.13,26
- Children witnessing violence. Children who witness violence far outnumber those who are directly victimized. A 1993 study by the National Institute of Mental Health conducted in Washington, D.C., revealed that 19 percent of first- and second-graders and 32 percent of fifth- and sixth-graders had been victimized, while 61 and 72 percent had witnessed violence, respectively.27
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
The Family Physician's Role
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.
Barriers to Recognizing Victims of Violence
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.
The Role of the Family Physician in the Identification and Treatment of Family Violence
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.
AAFP Initiatives to Decrease Family Violence
Among activities for the American Academy of Family Physicians (AAFP) to consider are the following:
- Developing or adapting teaching modules for members to present to medical students, residents, hospital staff and community groups43,44;
- Creating an ongoing education program for members on screening, recognition and treatment of violence, including distribution of the American Medical Association's guidelines for history-taking around issues of violence and abuse;
- Supporting or developing university-, hospital- or office-based protocols and policies about family violence43,45;
- Publicizing to members the hot-line numbers for organizations that help physicians and patients deal with abuse;
- Offering continuing medical education for members to increase their skills in screening for, identifying and treating cases of domestic violence;
- Participating in public policy initiatives and legislative reform to protect victims and rehabilitate batterers and partnering with other organizations committed to decreasing family violence;
- Promoting reasonable and responsible control of firearms and other weapons.
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.
- U.S. Preventive Services Task Force. Guide to clinical preventive services: report of the U.S. Preventive Services Task Force. 2d ed. Baltimore: Williams & Wilkins, 1996.
- Council on Scientific Affairs, American Medical Association. Violence against women: relevance for medical practitioners. JAMA 1992;267:3184-9.
- Goldberg WG, Tomlanovich MC. Domestic violence victims in the emergency department. New findings. JAMA 1984;251:3259-64.
- Abbott J, Johnson R, Koziol-McLain J, Lowenstein SR. Domestic violence against women. Incidence and prevalence in an emergency department population. JAMA 1995;273:1763-7.
- Feldhaus KM, Koziol-McLain J, Amsbury HL, Norton IM, Lowenstein SR, Abbott JT. Accuracy of three brief screening questions for detecting partner violence in the emergency department. JAMA 1997;277:1357-61.
- Dearwater SR, Coben JH, Campbell JC, Nah G, Glass N, McLoughlin E, et al. Prevalence of intimate partner abuse in women treated at community hospital emergency departments. JAMA 1998;280:433-8.
- McLeer SV, Anwar R. A study of battered women presenting in an emergency department. Am J Public Health 1989;79:65-6.
- Randall T. Domestic violence intervention calls for more than treating injuries. JAMA 1990;264:939-40.
- Reynolds S. TV violence: an American public health epidemic. California Physician 1993:10(10);41-5.
- Knapp JF, Dowd MD. Family violence: implications for the pediatrician. Pediatr Rev 1998;19:316-21.
- Child Abuse and Neglect National Statistics, U.S. Department of Health and Human Services. Fact sheet, 1997 and the National Committee to Prevent Child Abuse. Child abuse and neglect statistics. April:1995.
- Council on Scientific Affairs, American Medical Association. Adolescents as victims of family violence. JAMA 1993;270:1850-6.
- Hennes H. A review of violence statistics among children and adolescents in the United States. Pediatr Clin North Am 1998;45:269-80
- Gelles RJ. Family violence, 2d ed. Newbury Park: Sage Publications, 1987:82
- Straus MA, Gelles RJ. Physical violence in American families. New Brunswick, N.J.: Transaction Publishers, 1990.
- National Center on Elder Abuse, American Public Welfare Association. National Elder Abuse Incidence Study, 1996.
- Eisenstat SA, Bancroft L. Domestic violence. N Engl J Med 1999;341:886-92.
- Meyer H. The billion-dollar epidemic. In: Violence: a compendium from JAMA, American medical news and the specialty journals of the AMA. Chicago: American Medical Association, 1992.
- Milner JS, Robertson KR, Rogers DL. Childhood history of abuse and adult child abuse potential. J Fam Violence 1990;5(1):15-34.
- Cappell C, Heiner RB. The intergenerational transmission of family aggression. J Fam Violence 1990;5(2):135-52.
- Taliaferro EH, Salber P. The physician's guide to domestic violence: how to ask the right questions and recognize abuse…another way to save a life. Volcano, Calif: Volcano Press, 1995.
- Council on Scientific Affairs, American Medical Association. Assault weapons as a public hazard in the United States. JAMA 1992;267:3067-70.
- Saltzman LE, Mercy JA, O'Carroll PW, Rosenberg ML, Rhodes PH. Weapon involvement and injury outcomes in family and intimate assaults. JAMA 1992;267:3043-7.
- Kellermann AL, Reay DT. Protection or peril? An analysis of firearm-related deaths in the home. N Engl J Med 1986;314:1557-60.
- Callahan CM, Rivera FP. Urban high school youth and handguns. A school-based survey. JAMA 1992;267:3038-42.
- Koop CE, Lundberg GD. Violence in America: a public health emergency. Time to bite the bullet back [Editorial]. JAMA 1992;267:3075-6
- Knapp JF. The impact of children witnessing violence. Pediatr Clin North Am 1998;45:355-64.
- Pynoos RS, Eth S. Witness to violence: the child interview. J Am Acad Child Psychiatr 1986;25:306-19.
- Freund K, Blackhall L. Detection of domestic violence in a primary care setting [Abstract]. Clin Res 1990;38:738A.
- McFarlane J, Parker B, Soeken K, Bullock L. Assessing for abuse during pregnancy. Severity and frequency of injuries and associated entry into prenatal care. JAMA 1992;267:3176-8.
- Helton AS, McFarlane J, Anderson ET. Battered and pregnant: a prevalence study. Am J Public Health 1987;77:1337-9.
- Randall T. Adolescents may experience home, school abuse; their future draws researchers' concern. JAMA 1992;267:3127-8, 3131.
- Coleman VE. Violence in lesbian couples: a between groups comparison. (doctoral thesis) San Diego, California: School of Professional Psychology; 1990.
- Brand PA, Kidd AH. Frequency of physical aggression in heterosexual and female homosexual dyads. Psychol Rep 1986;59:1307-13.
- Pillemer K, Finkelhor D. The prevalence of elder abuse: a random sample survey. Gerontologist 1988;28:51-7.
- Anetzberger GJ, Lachs MS, O'Brien JG, O'Brien S, Pillemer KA, Tomita SK. Elder mistreatment: a call for help. Patient Care 1993;27:93-5,99-100,104 passim.
- Hamberger LK, Saunders DG, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med 1992;24:283-7 [published erratum appears in Fam Med 1992;24:568]).
- Rodriguez MA, Bauer HM, McLoughlin E, Grumbach K. Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. JAMA 1999;282:468-74.
- Caralis PV, Musialowski R. Women's experience with domestic violence and their attitudes and expectations regarding medical care of abuse victims. South Med J 1997;90:1075-80.
- Friedman LS, Samet JH, Roberts MS, Hudlin M, Hans P. Inquiry about victimization experiences. A survey of patient preferences and physician practices. Arch Intern Med 1992;152:1186-90.
- Council on Ethical and Judicial affairs, American Medical Association. Physicians and domestic violence. Ethical considerations. JAMA 1992;267:3190-3.
- Sugg NK, Inui T. Primary care physicians' response to domestic violence. Opening Pandora's box. JAMA 1992;267:3157-60.
- Alpert EJ, et al. Educating the nation's physicians about family violence and abuse. Acad Med 1997:72 (suppl 1):Sv-viii,S3-115.
- Chez RA, Horan DL. Response of obstetrics and gynecology program directors to a domestic violence lecture module. Am J Obstet Gynecol 1999;180:496-8.
- Sheridan DJ, Taylor WK. Developing hospital-based domestic violence programs, protocols, policies, and procedures. AWHONNS Clin Issues Perinat Womens Health Nurs 1993;4:471-82.
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