Trauma, 7th Ed.

CHAPTER 46. Social Violence

James W. Davis

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.2,57 Despite this potential knowledge base, physicians are often hesitant to utilize this information.810 Early recognition and intervention may prevent future incidents and decrease rates of complications such as posttraumatic stress disorder.2,1012 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 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

Image 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

Image 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,36,43directly 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.

Image 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.45,46

Image Summary on Domestic Violence

Domestic violence is common and commonly undiagnosed. As recommended in the landmark position paper by the Eastern Association for the Surgery of Trauma (1999),16 all female trauma patients be screened for domestic violence. The use of a specific screening tool 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 includes physical, sexual, and psychological or emotional abuse as well as neglect or abandonment. Self-neglect is most common and the prevalence of elder abuse in the community is estimated to range from 2 to 10%.47 A World Health Organization review of studies from the United States, Canada, Great Britain, and Finland found combined rates of elder abuse of 4–6%.48 The estimates on institutional mistreatment are limited, but from 1999 to 2001, fully one third of nursing homes in the United States were cited for abuse violations.49

There is a significant association between elder abuse and risk of morbidity and mortality. One prospective cohort study found a 3-fold 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.50 Elder abuse is most common in women and persons older than 80 years of age with a family member being the abuser in 90%.51

Image 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.52

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 advocated53:

Do you feel safe where you live?

Who prepares your meals?

Who handles your checkbook?

The responses might lead to further questions and additional information may need to be obtained both from others who are not under suspicion and from physical findings.

Image 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.


Elder abuse is less common than IPV (2–10%) but 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.


Image History of the Problem

The issue of interpersonal violence as a public health problem has gained significant national attention. The United States exceeds all other high-income nations in violent death (graph from up to date?).54 The United States also has the highest youth homicide rate of the 26 industrialized nations.55 Gunshot suicide deaths account for 49% of the violent deaths and occur 30 times more frequently in the USA than in Great Britain.56 Over 1.5 million emergency department visits are due to violent injury annually in the United States.57 In 2000, the total cost associated with fatal and nonfatal injuries due to violence was estimated to be at least $70 billion.58 Most violence occurs not with strangers but with intimate partners, friends, and acquaintances.5961

Image 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.56,62 Men younger than 65 years were 4-fold 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.63

Increased concerns about violence have led to more Americans obtaining and carrying firearms for protection,64 but this actually leads to increased risk of firearm injury or death. It is estimated that 40–50% of American households have guns.80,65 A gun in the home is associated with a 40-fold greater chance of killing a family member or acquaintance (homicide, suicide, or accidental) deaths than an intruder in self-protection.66

Alcohol and drug use are also associated with an increased risk of violence. 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 21.67 Alcohol is involved in one half to two thirds of homicides, half of serious assaults and more than 25% of rapes.68

A national survey of youth gangs reported more than 20,000 gangs with 650,000 members in 1995.69 More than 94% of cities with a population greater than 100,000 have street gangs.70 Individuals that participate in gangs are more likely to be involved in fights, take weapons to school, and use drugs or alcohol at school.71

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.72


Physicians are poised in key positions from which to impact the lives of victims of interpersonal violence.73 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.74 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.75 Indeed, when patients were given an opportunity to tell physicians how to intervene in family conflict, the overwhelming majority thought physicians should ask.10


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.76

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 competencies77 and interventions should be evidence-based.


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