Chapter 46: 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.

• Suicides and homicides are the second and third leading causes of death among children and youth under the age of 21.²

• Overall injury and violence remain the leading cause of death for persons aged 1–44.²

• One person dies every 4 minutes as a result of intentional injury.³

• Intimate partner violence is the most common cause of injury to women in the United States causing nearly 2 million injuries a year.^4,5,6,7

The literature is replete with studies identifying risk factors for interpersonal violence.^2,8,9,10 Despite this potential knowledge base, physicians are often hesitant to utilize this information.^11,12,13 Early recognition and intervention may prevent future incidents and decrease rates of complications such as post-traumatic stress disorder.^13,14,15 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.

Intimate partner violence, or also known as 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 relationships. 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.”^16,17 Other reports have acknowledged that child^18,19 and elder abuse may also be included in the spectrum of “domestic violence.”²⁰ Intimate partner violence (IPV) and elder abuse will be covered here and child abuse will be addressed in Chapter 43: The Pediatric Patient.

Intimate partner 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.”²¹ 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.²² The legal right of men to beat their wives was not abolished until 1871 in the United States.²³ Until the 1970s, assaults on wives were considered misdemeanors, when an equal assault against a stranger would have been considered a felony.²⁴ 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.²⁴

Public awareness campaigns such as nomore.org have heightened awareness on this issue. Multiple medical professional organizations recognize IPV as a public health problem not limited to specialties. The responsibility resides with all the treating physicians and surgeons to diagnose and to aid in providing resources to the victim.^17,25,26

Incidence and Prevalence

The actual incidence of intimate partner violence is unknown as definitions and estimates vary widely. However the estimated statistics are alarming. Currently, the CDC estimates more than 12.7 million women and men have been affected by IPV.²⁷ This effects 24 people every minute.²⁷

The National Intimate Partner and Sexual Violence Survey from the CDC and National Institute of Justice and Department of Defense estimates every year that 6.0% of women and 5.0% of men in the United States experienced physical violence, rape, and/or stalking by an intimate partner. Over a lifetime, 35.6% of women and 28.5% of men underwent some form of abuse including 19.3% of these women were raped.²⁷ The rates of IPV were highest for persons ages 18–24.²⁸ Women are more likely to experience rape, stalking and physical violence where men are more likely to experience physical violence alone.²⁹ In addition, 51.5% of female rape victims reported being raped by their intimate partner.²⁹

These rates are similar to the report from World Health Organization (WHO). They found worldwide a 35% prevalence of women experienced physical or sexual violence with 30% prevalence rate involving intimate partner violence.³⁰ In effect, one out of three women around the world has been beaten, coerced into sex, or otherwise abused during her lifetime.³¹

One report from the National Institute of Justice and the Centers for Disease Control and Prevention (CDC) estimated 1.5 million women are physically assaulted or raped by an intimate partner in the United States annually.³² The National Violence Against Women Survey also 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.²⁹ As a result of violence, the estimated cost is more than $8.3 billion.^33,34

There is less data of IPV within the lesbian, gay, bisexual, and transgender community. However, prevalence rates are estimated to be similar or even higher than in heterosexual community. CDC found bisexual victims experienced higher rates of IPV, with a 75% lifetime prevalence in bisexual women compared to 46.4% of lesbian and 43.3% of heterosexual women. Gay and bisexual men also had higher rates of IPV violence than heterosexual men.³⁶ Bisexual survivors are more likely to experience physical and sexual violence while transgender victims are more likely to experience physical violence. Gay men were more likely to experience IPV in forms of intimidation and harassment and found homicide victims highest among gay men (76.2%) in the LGBT community.^35,36

The cumulative lifetime prevalence to domestic violence of women seen in the emergency department was 40–60%.^32,37,38 Twelve to 25% of visits by women to the emergency department were from domestic violence.³⁷ Severe physical violence is experienced by 24.3% of women by an intimate partner, including being slammed against something or assaulted with fists or hard objects.²⁹

A WHO multicountry study and US studies on domestic violence found those who reported IPV found wide range of physical problems and were twice as likely to experience depression, alcohol abuse, and had a 4.5-fold increased risk of suicide attempts.^30,44 In some regions, women were 1.5 times more likely to acquire HIV.^30,31

Victims are more likely to have long-term health and mental problems such as depression, PTSD, drug and alcohol abuse than nonvictims.^25,27,40

Physical abuse occurs as well in 7–20% of pregnancies.³⁹

In the United States, 17% of all homicide victims involved IPV. Of these cases, 77% of the victims were female and 62% of the female homicide victims were committed by their intimate partner.^41,42 This averages to more than three women murdered everyday by husbands or their partner.⁴³ Violence policy center found that of all murder suicides, 72% of cases involved an intimate partner which 94% of the victims were female.⁴¹ Worldwide, 38.6% of female homicides were caused by an intimate partner.⁴⁴

The majority (52%) of female homicides are committed with guns.⁴² Women are 3.6 times more likely to be shot by a spouse or ex-significant other than by a stranger.⁴⁵ Women are 6 times more likely to be killed if a gun is in the house in IPV homicides.⁴² 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.⁴⁶ Child battering occurs in 59% of the homes with spousal abuse and may be as high as 77% with severe wife abuse.^47,48 The victim is frequently demoralized, and is so lacking in self-esteem that it is difficult to leave the situation.⁴⁹

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.⁵⁰

A three-phase cycle has been described for battering, the first with a gradual buildup 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.⁴⁹

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 victims presenting to the emergency department, 23% had presented 6–10 times previously and 20% had 11 prior emergency department visits.⁵¹ 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.⁵² Victims of domestic violence view physicians as least effective in helping them compared to women’s shelters, social services, clergy, police, and lawyers.⁵²

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, significantly more injured than accident victims (P < 0.001) and unwitnessed injuries are significant markers for IPV.^53,54

Because victims of IPV may be fearful or ashamed, nontraumatic complaints predominate as reasons for physician visit. In one study, 78.4% of IPV victims had medical complaints and 72% were never identified as victims of abuse.⁵⁵ 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.⁵⁶ However, domestic violence victims were not offended when asked about abuse in a nonjudgmental manner.⁵⁷ 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.⁵⁸

The use of a specific screening tool for domestic violence has been shown to be more effective than routine social services evaluation.⁵⁷ Multiple screening tools are available and explicit questions should be directed to all trauma patients to identify recent inflicted injuries and safety at home. These questions take about 20 seconds to perform and can identify up to 65–70% of the victims of domestic violence.⁵⁹

Although some data suggest battered women prefer nonface to face screening, directly asking about abuse has been shown to yield more positive results than written questionnaires.^56,60,61 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.”

The US Preventive Services Task Force (USPSTF) recently updated their recommendations to screen asymptomatic women of childbearing age for IPV and provide referral services to those who screen positive. The USPSTF found adequate evidence that screening can identify abuse and other studies have found effective interventions can reduce violence.^62,63 The American College of Surgeons, American College of Physicians, American College of Obstetrics and Gynecology, American Academy of Orthopedic Surgeons, American Medical Association, Eastern Association for Trauma and the Western Trauma Association all recommend screening for IPV.^{17,20,24,25,26}

Once the diagnosis of IPV 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 IPV, 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.^64,65

Intimate partner violence is common and commonly undiagnosed. As recommended in the position statement by American College of Surgeons, all trauma patients should be routinely screened for intimate partner violence.¹⁷ The use of a specific screening tool without the partner present is strongly recommended. Trauma centers and trauma surgeons should have ongoing education about domestic violence to improve the recognition and management of this epidemic problem.

Elder Abuse

Elder abuse includes physical, sexual, and psychological or emotional abuse as well as neglect or abandonment, or even financial exploitation. The majority of elder abuse and neglect is suspected to be underreported which may stem from lack of professional awareness, victim reluctance, or even cognitive impairments in reporting.^66,67 Health care professionals tend to underestimate elder abuse and when detected, approximately 50% of elder abuse cases are reported.⁶⁶

Incidence and Prevalence

Similar to IPV, the exact incidence is unknown as elder abuse is largely underreported. Recent reports estimate 7.6–10% incidence of elder abuse.^67,68,69 In one study, 88.5% of abused elders experienced psychological abuse, where 19.7% reported physical abuse, and 29.5% experienced neglect.⁷⁰ Older people with cognitive impairments, physical disabilities, or mental health problems were found to be at higher risk of being abused.^71,72,73 Alarmingly, 34–62% of caregivers were found to abuse elders with dementia.^70,72,74 Elder abuse is found to be most common in women and persons older than 75 years of age. A family member is identified as being the abuser in 90% of the reported cases.^75,76,77 Cultural differences and language barriers in vulnerable groups may hinder identification of abuse, especially in Latino, Asian Pacific Islander elders.^78,79

Worldwide, the incidence of elder abuse is predicted to increase as the global population is expected to more than double to approximately 1.2 billion in 2025.⁸⁰ A World Health Organization review found 4–6% combined rate of elder abuse in developed countries.⁸¹ The highest prevalence rate of elder abuse is found to occur in more developed countries rather than developing countries.⁷⁷

The rates of elder abuse in nursing homes are alarming. One study found over half of the nursing home staff reported physical violence, neglect, and mental abuse of their elderly patients. The majority of these cases involved neglect.⁸² Previous studies from 1999 to 2001, found one-third of nursing homes in the United States were cited for abuse violations.⁸³

There is a significant association between elder abuse and risk of morbidities such as depression, increased rates hospitalization, increased emergency service use and mortality.^{73,84,85,86,87} One study found elder abuse, especially neglect, was associated with significantly increased risk of mortality.⁸⁵ One prospective cohort study found a threefold increase in mortality for persons ages 65 and older that were referred to Adult Protective Services for mistreatment and a 1.7-fold increase for those with self-neglect.⁸⁸

Diagnosis

Some of the findings are similar to other forms of abuse: skin injury and tears, and bruising. Fractures in the elderly are unfortunately common, but fractures in places besides the hip, vertebrae or wrists, or spiral fractures may be suspicious of abuse. Malnutrition and dehydration may be a sign of neglect in a dependent elder.^89,90 As with IPV, there are a number of screening tools that may be used for assessment of elder neglect and/or abuse. A simple three question screen has been advocated⁹¹:

1. Do you feel safe where you live?

2. Who prepares your meals?

3. Who handles your checkbook?

The responses might lead to further questions and additional information may need to be obtained.

Treatment and Referral

When elder abuse is suspected, as in IPV, medical treatment comes first. If there is reason to believe that an elder is suffering from abuse, neglect, or exploitation, referral for possible elder abuse should occur. Reporting elder abuse is required in most states. Documentation of injuries on the medical record should be meticulous.

Summary

Elder abuse is less common than IPV (7.6–10%) but continues to trend upward. It is associated with significant morbidity and mortality. Seniors with risk factors should undergo brief screening questions as listed above. If elder abuse or mistreatment is suspected based on answers to the screening questions or physical findings, further assessment is indicated. If there is reason to believe that there is abuse or neglect, reporting and careful documentation are essential.

History of the Problem

The issue of interpersonal violence as a public health problem has gained significant national and worldwide attention. Worldwide, violence causes more than 1.3 million deaths each year and is the fourth leading cause of death for people aged 15–44.⁹² The United States significantly exceeds all other high income nations in violent death.⁹² The United States also has the highest youth homicide rate out of all the industrialized nations.^93,94 In 2013, National Research Council and Institute of Medicine found US males and females with shorter life expectancies than other economically developed countries with homicide and suicide accounting for about a quarter of the years of life lost for US men.⁹⁴

Gunshot suicide deaths account for 51% of violent deaths and occur 17 times more frequently in the United States than in Great Britain.^95,96,97,98 Young men in the United States aged 16–19 are 5 times more likely and males aged 20–24 are 7 times more likely to die from violence.⁹⁴ Worldwide, more than 500 young adults are murdered daily.⁹²

Over 2.4 million emergency department visits are due to violent injury annually in the United States.⁹⁹ In 2010, the total cost associated with fatal and nonfatal injuries due to gun violence was estimated to be at least $174 billion.¹⁰⁰ Most violence occurs not with strangers but with intimate partners, friends, and acquaintances.^101,102,103

Risk Factors

Injuries resulting from violence occur when people have learned to use force to “solve” problems. Most age and population groups in the United States are actually at relatively low risk. A number of risk factors have been identified for community violence and related injury: age, socioeconomic status, race, access to firearms, alcohol and other drug use, gang involvement, exposure to domestic violence and child abuse, and media violence. The most significant risks are male gender, being adolescent or young adult, and low socioeconomic status.^92,95,104 Men younger than 65 years were fourfold more likely to be murdered than women or people over 65 years of age. Homicide is the second leading cause of death for men between 15 and 24 years and the leading cause in African American men between 15 and 24 in the United States.^94,95 Sixty-six percent of all homicides involve the use of firearms.⁹⁴

Increased concerns about violence have led to more Americans obtaining and carrying firearms for protection, but this actually leads to increased risk of firearm injury or death. It is estimated that 40–50% of American households have guns.^105,106,107 A gun in the home is associated with a 40-fold greater chance of killing a family member or acquaintance (homicide, suicide, or accidental) than an intruder in self-protection.¹⁰⁸

Alcohol and drug use are also associated with an increased risk of violence.¹⁰⁹ In one study, individuals who began drinking before age 14 were significantly more likely to have been in an alcohol related fight than those who began drinking after age 21.¹¹⁰ Alcohol is involved in one-half to two-thirds of homicides, half of serious assaults and more than 25% of all rapes.¹¹¹ Approximately 36.7% of homicides involved alcohol where majority of victims had a blood alcohol content of greater than or equal to 0.08 g/dL.⁹⁵

Gang Violence

A national survey of youth gangs reported more than 30,000 gangs with 850,000 members in 2012, an increase in 20% from the previous year.¹¹² More than 85% of cities with a population greater than 50,000 have street gangs. Gangs were involved in approximately 16% of all homicides.¹¹² Individuals that participate in gangs are more likely to be involved in fights, take weapons to school, and use drugs or alcohol at school.^113,114

The media’s glamorized version of violence is seen by millions daily. The use of violence is an acceptable, if not the preferred method of dealing with conflict and used by heroes as well as villains. A longitudinal study of young adults demonstrated that those with childhood high violence television viewing were significantly more likely to have grabbed, pushed, or shoved their spouses and that the men in this group were three times more likely to be convicted of crimes.¹¹⁵

Surgeon’s Role

Physicians are poised in key positions from which to impact the lives of victims of interpersonal violence.¹¹⁶ The timing and proximity of our contact with the patient are crucial components of the formula for successful intervention.

There are barriers to intervening but despite these barriers, physicians can and should address the issue of intentional violence. Many professional organizations have published position statements and/or guidelines. Most guidelines advocate for the routine incorporation of questions regarding safety and exposure to interpersonal violence into the history. Alpert and colleagues have made a list of age specific screening questions that can be easily covered.¹¹⁷ The value of this routine asking is partly about identifying individual victims but also represents an opportunity to improve overall health care. Routine screening provides physicians with opportunities to express concern for the patient and to express the antiviolence message.¹¹⁸ Indeed, when patients were given an opportunity to tell physicians how to intervene in family conflict, the overwhelming majority thought physicians should ask.¹³

Violence in our society represents a complex, multifaceted problem. In many ways, violence is like a chronic disease. This “disease” is related to both lifestyle and environment. Sims and coworkers at Henry Ford Hospital found that trauma is a recurrent disease, with 44% having recurrent injury and an overall 5-year mortality rate of 20% clearly demonstrates that this “disease” should not be ignored.¹¹⁹

The enormity of this problem requires an ordered, disciplined approach such as that developed by the public health community to address infectious diseases.¹ This approach should include event surveillance, epidemiologic analysis, intervention design and evaluation, and a focus on prevention. Our educational efforts should be based on clear competencies and interventions should be evidence based.¹²⁰