Social Violence
Trauma care is, by definition, tertiary prevention or treatment. Understanding the root causes of the injury may aid in better comprehension and treatment of the trauma victim. Improvements in trauma care should incorporate consideration of the psychosocial aspects of such injuries as well as the needs of an impact on the larger health care system. Patients who are victims of family and community violence may have relatively simple traumatic injuries but often have complex psychosocial issues that affect their response to injury. Simply treating the injuries and not intervening with the underlying causes makes recidivism of these patients the likely end result. Early detection and efforts at prevention of interpersonal violence must be part of the trauma center’s prevention program.
Violence may be defined as “the intentional use of physical force against another person or against oneself, which results in or has a high likelihood of resulting in injury or death.”1 Its frequency is documented in the following facts. Homicides and suicides are the second and third leading causes of death among children and youth under the age of 21.2 Domestic violence is the most common cause of injury to women in the United States.3 One person dies every 4 minutes as a result of intentional injury.4 The literature is replete with studies identifying the scientifically proven risk factors for interpersonal violence.2,5–7 Despite this potential knowledge base, physicians are often hesitant to utilize this information.8–10 Early recognition and intervention may prevent future incidents and decrease rates of complications such as posttraumatic stress disorder.2,10–12 The statistics on death and injury from intentional violence are only the tip of the iceberg. The cost to society of violent behavior also includes the price of legal battles, incarceration, and the economic effects on the health care system as a whole, as well as the psychological stress to victims and the families of victims.3,4
The purpose of this chapter is to provide the practicing surgeon with some basic information on intentional violence with a focus on intimate partner and community violence, so that he or she may be a better provider of care for these patients with special needs.
DOMESTIC VIOLENCE
Domestic violence refers to those acts of interpersonal violence resulting in physical or psychological injury to members of the same family or household or to intimate acquaintances in heterosexual or homosexual. Another definition of domestic violence goes further, including “a pattern of coercive control consisting of physical, sexual, and/or psychological assault against former or current intimate partners.”13 Other reports have acknowledged that child14,15 and elder abuse may also be included in the spectrum of “domestic violence.”16 Intimate partner violence (IPV) and elder abuse will be covered here, child abuse will be addressed in the chapter on pediatric trauma.
Domestic violence is not new, it has long plagued mankind. A 15th-century scholar argued that a man should beat his wife, “not in rage but out of charity and concern for her soul.”17 English Common Law established “the Rule of Thumb” in 1895, stating that a husband could not beat his wife with a switch greater in diameter than the width of his thumb.18 The legal right of men to beat their wives was not abolished until 1871 in the United States.19 Until the 1970s, assaults on wives were considered misdemeanors, when an equal assault against a stranger would have been considered a felony.20 In 1992, it became a requirement of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) that all accredited hospitals have policies and procedures in their emergency departments and ambulatory care facilities for identifying, treating, and referring victims of abuse.20
Incidence and Prevalence
The actual incidence of intimate partner and/or domestic violence is not known. In 1985, C. Everett Koop, as U.S. Surgeon General, estimated that over 6 million women a year are beaten or physically abused by boyfriends or husbands in the United States, with an act of domestic violence occurring every 18 seconds. He also noted that battery and assault against women occurred more frequently than rape, mugging, and motor vehicle accidents combined.21 Both men and women can be victims of IPV, studies suggest that 30–85% of victims are women.22,23 Estimates of the incidence vary widely; the U.S. Department of Justice crime data brief on IPV reported almost 700,000 “nonfatal, violent victimizations” in 2001, and highlighted a nearly 50% decline in IPV against females since 1993.23 However, at the same time a report from the National Institute of Justice and the Centers for Disease Control and Prevention (CDC) estimated that 1.5 million women are physically assaulted or raped by an intimate partner in the United States annually.24 The American Psychological Association Presidential Task Force on Violence and the Family put the number still higher, stating that 4 million women experience a serious assault by a partner during an average 12-month period.25 The National Violence Against Women Survey, done by the National Institute of Justice and the CDC in 2003, estimated 5.3 million IPV incidents against women annually, with more than 550,000 requiring medical attention, loss of 8 million days of paid work, and 5.6 million days of household productivity as a result of the violence.26
• The cumulative lifetime prevalence to domestic violence of women seen in the emergency department was 54–60%24,27
• 1 out of 3 women around the world has been beaten, coerced into sex, or otherwise abused during her lifetime28
• 12–25% of visits by women to the emergency department were from domestic violence27
• Physical abuse occurs in 7–20% of pregnancies29
• Women are 3.6 times more likely to be shot by a spouse or ex – significant other than by a stranger30
• 4 women are murdered everyday by husbands or boyfriends.
Additionally, marital violence is a significant predictor of physical child abuse. In one study, the probability of child battering increased from 5% with one act of marital violence to near certainty with 50 or more acts of wife battering.31 Child battering occurs in 59% of the homes with spousal abuse and may be as high as 77% with severe wife abuse.32,33
The victim is frequently demoralized, and is so lacking in self-esteem that it is difficult to leave the situation.34 Additionally, the threats of retaliation, injury to children or pets and death increase the victim’s fears and helplessness. Indeed, the risk of physical violence actually increases after moving out.35
Diagnosing Domestic Violence
A three-phase cycle has been described for battering, the first with a gradual build up of tension, then escalation with name calling, intimidation, and mild physical abuse. The second phase has an uncontrollable discharge, with verbal and physical attack and frequently injury. In the third phase, the abuser apologizes and asks for forgiveness and promises that it will not recur. With repeated cycles, the first phase increases in length, the violence may become more acute and the third phase decreases. The victim is frequently demoralized, and is so lacking in self-esteem that it is difficult to leave the situation.34
The second cycle for victims of domestic violence involves the failure to make the diagnosis even after the patient arrives in the emergency department. In a study of battered women presenting to the emergency department, 23% had presented 6 to 10 times previously and 20% had 11 prior emergency department visits.36 In 40% of cases with known domestic violence, physicians made no response at all and in 92% of cases, physicians made no referral for the abuse.37 Victims of domestic violence view physicians as least effective in helping them compared to women’s shelters, social services, clergy, police, and lawyers.37
There are some characteristics of injury type and location in domestic violence. Injuries tend to be central; face, head, neck, breast, and abdomen versus more peripheral injuries in accidents. In one study of injury locations, the head, face, neck, thorax, and abdomen significantly more injured than accident victims (P < 0.001).38
Because victims of IPV may be fearful or ashamed, nontrauma complaints predominate as reasons for physician visit. Even after violent episode, only 23% had injury related complaints. Domestic violence victims rarely volunteer information; only 13% after battering either told staff or were asked about the possibility of abuse.39 However, domestic violence victims were not offended when asked about abuse in a nonjudgmental manner.40 Further, the failure of health care providers to ask about domestic violence may be perceived as evidence of a lack of concern and add to feelings of entrapment and helplessness.41
The use of a specific screening tool for domestic violence has been shown to be more effective than routine social services evaluation.40 One such tool, the Partner Violence Screen,42 consists of three questions, takes about 20 seconds to perform and can identify up to 65–70% of the victims of domestic violence (Fig. 46-1). Although some data suggest battered women prefer nonface-to-face screening,36,43 directly asking about abuse has been shown to yield more positive results than written questionnaires.44 Screening for IPV should be approached in a quiet environment, separate from the partner, with a nonjudgmental opening such as “because we see a lot of patients coping with abusive relationships, we now ask about domestic violence routinely.”
FIGURE 46-1 Partner violence screen. (Reprinted with permission from Feldhaus KM, Koziol-McLain J, Amsbury HL, et al. Accuracy of three brief screening questions for detecting partner violence in the emergency department. JAMA. 1997;277:1357–1361. Copyrighted 1997, American Medical Association. All rights reserved.)
Although there is not good data about the effectiveness of screening or even intervention for domestic violence, numerous organizations (American College of Physicians, American College of Obstetrics and Gynecology, American Medical Association, Eastern Association for Trauma and the Western Trauma Association) recommend screening for domestic violence.
Treatment and Referral, Documentation, and Reporting
Once the diagnosis of domestic violence has been made, the responsibilities are to treat the patient, reassure them about safety, and make the appropriate referral to social services. It is important to carefully document the injuries in the medical record. Regardless of the legal requirement to report domestic violence, failure to do so may have lethal consequences. In several studies of women murdered by their spouses or boyfriends, the majority had accessed the health care system within a year or two of their deaths, most for injury and even when the diagnosis was made, there was no referral for the abuse.
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