• Violence (Position Paper)

    Definition of Violence

    The World Health Organization defines violence as “the intentional use of physical force or power, threatened or actual, against oneself, against another person or against a group or community, which either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.”1 Violence and abuse may be physical, sexual, or psychological. Three broad subtypes of violence exist: self-directed, interpersonal, and collective. Self-directed violence includes suicide and self-abuse. Interpersonal violence is violence among individuals, including violence among related individuals in the context of a family or extended family, and violence among unrelated individuals who may be friends, acquaintances, or strangers. Collective violence includes social, political, and economic violence. Self-directed, interpersonal, and collective violence are overlapping phenomena which occur within a larger social and cultural context. Common economic, social, and cultural risk factors influence all three. Vulnerable populations are often at increased risk of all three forms of violence. All violence is functional, intended to dominate, punish, control, harm, or eliminate an individual, a group, or a community. As physicians, we have many opportunities to identify patients at risk of victimization or perpetration, and to prevent or influence the outcomes associated with violence for our patients.

    Violence occurs in the context of a broad range of human relationships. Interpersonal violence within the family includes child abuse and neglect, sibling violence, intimate partner violence, elder abuse and neglect, and abuse and neglect of pets and other animals. Beyond the family context, interpersonal violence includes dating violence (also called adolescent relationships violence), peer violence, bullying, stalking, rape, community violence, and school violence. Collective violence is composed of many individual acts of interpersonal violence organized within a larger social and cultural context, and includes gang violence, hate crimes, mob behavior, human trafficking, sexual exploitation, and slavery. Also included within the scope of collective violence is oppression based upon gender, race, sexual orientation, social class, national origin or religion, and state-sponsored violence such as terrorism, genocide, war, and war-associated rape.2,3 There is a growing body of evidence linking the many forms of violence to adverse health effects. As family physicians, we need to understand this link and work with our patients to minimize the negative health effects associated with violence.

    Incidence & prevalence—United States and Worldwide

    Every family physician knows patients in his or her practice who have experienced violence—survivors of child abuse, sexual assault, or intimate partner violence; war veterans; refugees from high conflict regions of the world; individuals who have been the target of a hate crime, etc. Many patients who have been exposed to violence will present with symptoms of posttraumatic stress disorder (PTSD), depression, anxiety, substance abuse disorders, chronic pain syndromes, or chronic health problems such as diabetes or heart disease. In others, however, the effects of violence may not be obvious, and the physician may be unaware of histories of violence and trauma. How many of our patients have been exposed to one or multiple forms of violence?

    Understanding the total disease burden of violence in family medicine clinics is challenging because of limitations in the current state of our knowledge. No comprehensive national or international epidemiological studies exist to document the total disease burden of all forms of violence, in part because the public health science of violence is at an early stage of development. Operational definitions are still evolving, and researchers have generally focused on specific types of violence and used varying methodologies. We lack comprehensive national and international public health systems of violence surveillance. Another factor that complicates family physicians’ understanding of the impact of violence upon their patients’ lives is the fact that family physicians have a well-documented optimistic bias and consistently and dramatically underestimate the number of patients in their own practices who have experienced violence.

    In spite of the limitations, sound evidence exists documenting the high prevalence in the United States of some specific forms of violence. One in five U.S. children experience one or more forms of child maltreatment4: 1 percent are victims of sexual abuse; 4 percent are victims of child neglect; 9 percent are victims of physical abuse; and 12 percent are victims of emotional abuse. Maltreatment is a significant cause of child mortality. In 2008, an estimated 1,740 children up to age 17 died from abuse and neglect, a rate of 2.3 per 100,000 children.5 Homicide is the second leading cause of death for children and young adults 10 to 24 years old.6 For teenagers in grades nine through twelve, 31.5 percent report being in a physical fight in the past 12 months, 17.5 percent report carrying a weapon (gun, knife, or club), and 19.9 percent report being bullied on school property.7 In an emerging area of concern, between 9 and 35 percent of young people say they have been victims of aggression through a variety of forms of social media.8 According to the 2010 Pew Research Center Teens and Mobile Phones survey, one in four 12- to 17-year-old cell phone users (26 percent) have been bullied or harassed through text messages and phone calls, and 15 percent of teens say they have received a text message with a sexually suggestive nude or nearly nude image of someone they know, although only 4 percent of teens say they have sent such a message.14 According to the 2009 Youth Risk Behavior Survey (YRBS), 9.8 percent of high school students nationwide reported being the victim of physical violence at the hands of a romantic partner during the previous year.2 In a study of gay, lesbian, and bisexual adolescents, youths involved in same-sex dating are just as likely to experience dating violence as youths involved in opposite sex dating.3 A study published in the November 2009 issue of Pediatrics found that as many as one in five adolescent females and one in 10 adolescent males have been abused physically or sexually by a dating partner.4

    Rates of sexual assault are high for all ages. Nationally, 10 percent of women and 2 percent of men reported experiencing forced sex at some time in their lives9; 20 to 25 percent of women in college reported experiencing an attempted or completed rape in college10; and 11 percent of girls and 4 percent of boys in grades nine through twelve reported being forced to have sexual intercourse at some time in their lives.11 Regarding intimate partner violence (domestic violence), 22 percent of women report a physical assault by an intimate partner in their lifetime; 8 percent report sexual assault; and 5 percent report stalking, making for an overall victimization rate of 26 percent.12 Although research on war-related trauma is at an early stage, a large majority of war veterans experience traumatic events and are at higher risk of PTSD, depression, anxiety, and intimate partner violence. Among service members and veterans who served in the Afghanistan and Iraq wars, it appears that 10 to 18 percent will experience persistent PTSD following deployment.13

    Beyond U.S. borders, rates of violence are high throughout the world.3 Consider, for example, the World Health Organization Multi-country Study on Women’s Health and Domestic Violence, a survey of 24,000 women from 15 urban and rural regions in 10 countries with diverse cultural settings.24 Between 13 and 62 percent of women report physical abuse by an intimate partner while 6 to 59 percent report sexual abuse or rape by an intimate partner. The overall prevalence of physical and/or sexual abuse by an intimate partner ranged from 15 to 71 percent. Violence in all forms is a significant cause of mortality worldwide. In 2000, 1.6 million people died as a result of self-inflicted, interpersonal, or collective violence: 49 percent from suicide, 31 percent from homicide, and 19 percent from war-related violence.3

    Based upon our current understanding of the epidemiology of violence, family physicians cannot predict the total burden of violence in their patient population, but we can draw some conclusions: 1) many patients have experienced one or more forms of violence and trauma; 2) although risk varies among subpopulations, no economic, racial, religious, or other group is immune; and 3) there are important age and gender differences in the types of violence for which people are most at risk.

    Impact Upon Health

    Exposure to violence and abuse has long been associated with adverse health outcomes. Caring for patients with trauma histories, sometimes referred to as trauma-informed care, involves understanding the sources of trauma (e.g., interpersonal violence [physical, sexual, and emotional] and neglect, along with community and political violence) and how they interact within and between individuals and relate to health and healthcare utilization. Clinicians should also work from an appreciation of the ecological context in which violence occurs, accounting for the overlap and interplay between factors shaping the development and impact of domestic, intimate, interpersonal, neighborhood, community, and social and political violence.

    Violence impacts personal health through both direct tissue injury and the resultant morbidity and mortality (i.e., soft tissue damage, broken bones, organ damage, or death) and emotional trauma leading to mental health and stress-related conditions. Chronic and severe exposures to violence and abuse have been associated with the development of physical and mental disorders through a variety of proposed mechanisms that are violence specific. Studies controlling for tissue injury, maladaptive behaviors, lifestyle choices, and comorbid mental illness do not fully explain the associations between violence exposures and chronic illness, suggesting the presence of other pathophysiological mechanisms related to violence exposures that result in negative health-related outcomes.14 Research suggests that the primary mechanisms by which exposure to violence causes adverse health outcomes, such as chronic disease, include stress-mediated dysregulation of homeostatic pathways regulating neuroendocrine systems and the hypothalamic-pituitary-adrenal (HPA) axis. Neurobiological mechanisms include alterations in monoamines (serotonin and norepinephrine), hormones of the HPA axis (corticotropin-releasing hormone, adrenocorticotropin, cortisol, and dihydroepiandosterone), substance P, and neuropeptide Y. Many chronic illnesses that result in increased rates of mortality and years of potential life lost, including respiratory disorders (asthma and chronic obstructive pulmonary disease), obesity, cardiovascular disease, and cancer, have an independent risk associated with exposure to violence and abuse.

    For pregnant women, the impact is particularly serious. Homicide is a leading cause of traumatic death for pregnant and postpartum women in the United States, accounting for 31 percent of maternal injury deaths.13 Evidence exists that a significant proportion of all female homicide victims are killed by their intimate partners.14 Complications of pregnancy, including low weight gain, anemia, infections, and first and second trimester bleeding, are significantly higher for abused women,17,18 as are maternal rates of depression, suicide attempts, and use of tobacco, alcohol, and illicit drugs.19

    Longitudinal studies are beginning to describe associations between early childhood exposures to violence (both direct and indirect) and long-term health. The Adverse Childhood Experiences (ACE) study has been instrumental in establishing the relationship between childhood exposures to violence and abuse and risk for poor health-related outcomes in adulthood.15 Childhood adversity, characterized as abuse (emotional, physical, or sexual), neglect (emotional or physical), or household dysfunction (exposure to domestic violence directed at the mother, substance abuse, mental illness, parental separation or divorce, or maternal incarceration) has a strong, dose-dependent association with adult substance abuse, chronic obstructive pulmonary disease, depression, fetal death, health-related quality of life, illicit drug use, ischemic heart disease, liver disease, risk of intimate partner violence, multiple sexual partners (and early initiation of sexual activities), sexually transmitted infections, smoking (and early initiation of smoking), suicide attempts, unintended pregnancies, and adolescent pregnancy.16 The ACE study provides a conceptual framework describing how childhood adversity results in social, emotional, and cognitive impairment that predisposes the exposed to developing health risk behaviors associated with disease, disability, and social problems that ultimately result in early death. Girls and boys experiencing teen dating violence are more likely to suffer long-term negative behavioral and health consequences, including suicide attempts, depression, cigarette smoking, and marijuana use.8 Teen victims of physical dating violence are more likely than their non-abused peers to engage in unhealthy diet behaviors (taking diet pills or laxatives and vomiting to lose weight) and to engage in risky sexual behaviors (first intercourse before the age of 15 years old, not using a condom during last intercourse).9 Being physically or sexually abused by a dating partner leaves teen girls up to six times more likely to become pregnant and more than two times as likely to report a sexually transmitted disease.10

    Promoting Resiliency

    Identifying families in need can make a difference, and promising research suggests that we can address these poor health consequences and help prevent the cycle of violence. Psychotherapy designed for parents and children together can increase the quality of parenting and increase positive outcomes for children.13 We know that many abusive men are concerned about the devastating effects of violence on their children and the children of their partners; some men may be motivated to stop using violence if they have a better understanding of these effects.14 Finally, we know that a safe, stable, and nurturing relationship with a caring adult can help a child overcome the stress associated with exposure to violence.15

    Causes of Violence

    Although no single theory can describe all causes of violence and abuse, the Centers for Disease Control and Prevention recommends an ecological model as a framework for prevention and intervention. Seeking to understand factors that shape and create risk for the development of violence and abuse is not intended to excuse or mitigate personal responsibility for criminal or immoral behaviors. For primary prevention, however, it is critical to understand individual and social factors related to risk for perpetration of violence and abuse. Macrosocial factors are likely related to the development of violent behaviors. Power and control are often described as the underpinnings of violence and abuse. The patriarchal social structure can produce a social environment that supports male domination of women from the feminist perspective. Poverty, lack of economic opportunity, racism, and discrimination also support power differentials in society and are key drivers for the development of stress. Stress appears to be related to biologic pathways potentiating increased risk for developing maladaptive behaviors (e.g., substance abuse). Stress may also serve as a trigger for violent outbursts. The media likely play a role in the shaping of social norms related to violence and abuse and sustaining a culture of violence.17 Although alcohol abuse and substance abuse are strongly associated with violence, debate exists in the literature regarding the causal relationship between the two.18,19 A clinically relevant issue for clinicians is the transgenerational transmission of violence and abuse. Data strongly suggest that childhood exposures to violence and abuse put individuals at risk for developing perpetration behaviors.20,21 Many researchers have developed typologies to categorize perpetrators with common subtypes ranging from perpetrators who are psychotic with antisocial personality disorders and little hope for remediation to perpetrators of common-couples violence that occurs in the context of bidirectional relational dysfunction.22,23 Family physicians should watch for new research and future developments in violence prevention; in particular, they should look for findings that can be implemented in the primary care setting.

    Family Physician's Role

    Violence, Traumatic Stress, and the Family Medicine Patient

    Since violence and traumatic stress affect our patients and present to us as family physicians in many different ways, it is vital that we understand them in the context of our patients’ lives. As family physicians, we all see these patients in our offices and care for them daily. Recognizing the risk factors and asking questions about experiences with violence helps our patients understand that violence is related to their health conditions and gives them permission to talk about it within the context of their health. Many physicians worry about the time it may take once this line of questioning begins, but a study by Alpert29 showed that when answers to the screening questions suggest a history of abuse, it adds less than 10 minutes to the visit during which this information is uncovered. Often identifying the experiences leads to appropriate referral for counseling or use of other resources that help the patient. Recent clinical studies have supported the effectiveness of a two-minute screening for early detection of abuse of pregnant women.24 Additional longitudinal studies have tested a 10-minute intervention that was proved highly effective in increasing the safety of pregnant abused women.25 Understanding the many presentations of violence and its effects on our patients helps us provide better care.

    Family violence affects approximately a third of family physicians’ patients. Victims of family violence interact with the health care system twice as often as non-victims in a typical year. Patients welcome inquiry about violence and abuse as it relates to their health and the health of their families, as long as the inquiry is nonjudgmental. In a study performed by Burge and Schneider, nearly 97 percent of patients said they wanted their family physician to ask them about violence, regardless of whether they had a history of violence.26 Physicians should be equally attentive to screening for family violence in heterosexual, gay, lesbian, bisexual, and transgender patients. In addition to the traditional role as a secondary responder, primary care providers are ideally situated to be agents of primary prevention. Family physicians have expertise in case management; treating medical and mental health comorbidities associated with violence-exposed patients; developing a referral base for subspecialty evaluation and treatment; working from a preventive framework with longitudinal, therapeutic relationships with patients; and addressing at-risk behaviors that tend to occur with exposures to violence and abuse.

    Some presentations (anxiety, depression, and other mental health disorders; chronic pain syndromes such as fibromyalgia and pelvic pain; and multiple somatic complaints) are much more likely than others to be related to violence. It is important for family physicians to be aware of the issue, and to remember to inquire about their patients’ relationships and stressors.

    Family physicians have a responsibility to assess the level of risk for the patient and to support and empower patients in promoting harm-reduction strategies. Certain scenarios may put patients at particularly high risk for life-threatening family violence. These include a change in the severity and frequency of violence, drug or alcohol use, possession of a firearm, threats of suicide or homicide, recent break up, threats or assault with a weapon, attempted strangulation, and stalking behavior. Physicians must know the local and national resources available for patients affected by family violence and be able to refer patients appropriately, especially when these warning signs are identified. Physicians should be also familiar with local or national resources available to assist patients in danger that are responsive to the needs of special patient populations, such as gay, lesbian, bisexual, transgender, adolescent, elderly, or immigrant patients. Physicians should counsel patients about the acute and long-term risks posed by exposures to violence. The office staff and other team members in the family medicine practice should be trained to know the clues to violence and be able to respond, as many patients have strong relationships with other staff within a primary care office and may disclose to staff about the violence. A comprehensive response includes the following steps

    • Disclose the limits of confidentiality
    • Inquire about violence and assess immediate safety
    • Offer support and harm reduction
    • Offer supported referral
    • Provide primary prevention through patient education about healthy relationships

    Prevention of Violence-Primary and Secondary

    Prevention of Violence—Primary and Secondary

    Asking about violence exposures may be an intervention in and of itself, with education and patient-centered empowerment strategies increasing the capacity of victims to avoid future exposures. Family physicians can also use their clinical practice and office environment to educate patients about positive skills that may reduce the risk of violence. For example, providing educational materials on parenting skills and offering the Reach Out and Read program support the development of healthy parent-child relationships. Information on healthy relationships may help reduce the risk of teen dating violence and adult intimate partner violence. Evidence regarding the clinical burden of victimization and the prevalence of patients of family physicians reporting perpetration clearly defines a role for family physicians in the recognition and appropriate referral for treatment of perpetration as a primary prevention strategy.27,28 With adolescent patients, a discussion of their dating relationships and safety can help them understand appropriate behaviors they may not have considered.

    As family physicians, we have many opportunities to influence policies and bring together resources for our communities to help our patients cope with violence and its effects on health. Many family physicians are on local school boards where strong policies on school bullying are developed, work with police departments that have domestic violence response teams, and serve in nursing homes where elder neglect often occurs. It is our responsibility to create and contribute to policies designed to keep our communities healthy.


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    (1994) (2014 COD)