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