Surgeon General and Deputy Assistant Secretary for Health
Luncheon Address to the Uniformed Services
Academy of Family Physicians
April 26, 1983
(Greetings to hosts, guests; Gen. Mittemeyer, Gen. Chesney, Admiral Cox, possibly Capt. Higgins at head table)
It's a distinct pleasure to be with you today. You serve to remind me yet again that there really is something more to
medicine then decision memoranda with back-up appendices, options A through L, and budgets of carry-over funding. Medicine
can also be a hands-on, personalized activity they can make life just a little bit better for thousands of people every day
of the week.
And this is particularly true of your specialty, family medicine. As I hope you know, the Public Health Service has placed
among its top priorities the support of primary medical care, of which family medicine is the keystone. Also at the top of
our policy agenda are the twin concepts of health promotion and disease prevention. In these, too, are concepts that are part
and parcel of any solid family medicine practice. For these reasons -- and for many more -- I am delighted to be your guest
I know there was a time -- and not too long ago at that -- when family medicine was engaged in a defensive struggle to be
recognized and accepted. That day has passed. Everyone in medicine now knows that family medicine is central to the development
of contemporary, quality health care in this country. That point is been made most forcefully by the public. People want to
be helped by physicians who care about the whole person and about human relationships.
We can romanticize about the practice of family medicine. People like to do that and I suppose a little romance doesn't
really hurt. To be sure, a little goes a long way. But here, among our colleagues and peers, we needn't romanticize family
Yet, it's difficult to describe this particular specialty without using the kinds of adjectives that make your lower lip
quiver and your eye glasses fog up. Words like "caring" and "concerned" and "compassionate" . . .
"attentive" . . . "considerate." And frankly, as a pediatric surgeon, I sometimes get just a little annoyed.
Those are words that ought to be applied to the field of pediatrics. And, of course, geriatrics. And cardiology. And psychiatry.
And -- let's be candid -- to all of medicine.
I don't mind saying that the field of family medicine has done more than come into its own specialty. I believe it has
come into its own as a bellwether for our profession, demonstrating its leadership not only through good science and good
medicine . . . But through decent instincts and a general interest in the total person, not just in the particular complaint
that is presented.
For the next few minutes, I'd like to direct some difficult words your way exactly because you are family physicians and
you will understand what I'm talking about and even be able to do something about it. I want to talk to you about violence
. . . family violence . . . violence in the homes of America. A difficult, ugly topic. But one that we simply have to confront.
I do not think that it's out of line to say that family violence is one of our most serious public health problems today.
It's serious for several reasons:
People -- including many of our colleagues in medicine -- simply don't want to talk about it. The subject remains taboo
for many people, and, as a result, we can be led to believe that the evidence that has been accumulating -- and there is a
great deal of it -- may only be the tip of an iceberg. And that is a genuinely alarming thought.
Another reason is the profound effect that family violence has on its victims, particularly children, who carry the scars
with them into their adult years and tend to commit the very same acts of violence on their own children or on the children
And a third reason is this: family violence compromises virtually every other moral and ethical value we have. It is an ugly
and permanent stain upon our social fabric. To do nothing about it, to tolerated it at all, is to acquiesce in the disintegration
of personality, of human relationships, and of community life. I think it's that important.
What can we do about it? I don't want take up your time with a speech on good citizenship. That's hardly appropriate
for an audience in uniform. Instead, I want to talk about the role of the physician -- especially the family physician --
in confronting this phenomenon of family violence. There are things that need to be done . . . and can only be done by those
of us in medicine. And frankly, if we don't do these things, we shall not be forgiven by the innocent and vulnerable victims
of family violence . . . the children in particular.
One of the first things we need to do is become informed of the nature of family violence . . . what its manifestations may
be . . . who its victims are . . . and what are its medical outcomes. And we need good definitions to go by.
I am beginning with this definitional approach because frankly that has been one of the stumbling-blocks in this whole area.
In the absence of a clear public consensus on this issue, each person who has entered the field has been able to write a definition
unique to that person's own work. As a result, good people -- but busy people -- have lost patience and turned their energies
elsewhere. So we need to agree on whom and what we are talking about.
For example, we say we are concerned with "children." But there is no age limit, since the child-parent relationship
is a bond that stretches across the generations. Parents can abuse children who are "adults" in all other respects.
And children from the age of 7 or 8 and up can do violence to their parents, including homicide. Nevertheless, we use the
term "children" to indicate a "vertical" relationship and, in nearly every case, to indicate a difference
in physical and chronological age.
"Sibling" is easy enough to understand. Still, one of the problems with it is the traditional connotation of having
the same biological parents. We need to keep in mind that in many contemporary families one or both parents have come from
a previous marriage or relationship. Hence, the siblings may be the offspring of three or four adults, including the current
two. And, in my time at the Children's Hospital of Philadelphia, I have come upon families in which the adult partnerships
had changed so that none of the siblings were related to either parent.
"Parent" is a term that should also be simple enough to understand. However, there is sufficient evidence from violent
families to make us use the term in its most elastic sense. That is, as I mentioned a moment ago, a "parent" may or
may not be a biological relative to a child and may not even be legally responsible. For example, a new husband may assault
his wife's older daughter, a young woman he has not legally adopted. This is an all-too-familiar story in what is called
"acquaintance rape." The term "parent," therefore, carries the connotations of authority or power within the
family, as well as an implied age difference.
And finally, what is the definition of the word "family" itself? In families with a record of violence, it is difficult
to say the members are held together with a bond of love. Because of the arrangements and re-arrangements of partners in so
many contemporary families, as physicians we need to be careful about requiring a legal basis for the term. And there are
too many instances of battered spouses from childless homes to begin defining the family is essentially multi-generational.
If any of you remember the trouble this term raised with the "White House Conference on Families" in 1980, you will
know that whoever tries to define the word must do so with care and be prepared for an argument. However, when the problem
of violence comes up, I think the most workable definition is this:
A family is a combination of two or more people who have, themselves, accepted a bond that allows personal, direct access.
In other words, they define the relationship through which they get at each other.
In a way this is a perverse and upside-down view of a traditional relationship. In a traditional sense, a family is a combination
of people who accept a bond that requires each one to love and care for the other. This is what the "marriage vows"
and christening and baby-naming ceremonies are all about. I'm not an anthropologist, but I'm sure you remember, as
I do, those gentle little ceremonies of every culture that are covenants between people, pledges to be close and be caring
as a "family."
The horrible part about family violence is that the violator perversely uses the human covenant as a way to harm another.
It is as if the marriage vow, for example, were a scandalon, the tiny tripwire on a mousetrap. By taking a bow, one partner
trips the scandalon and thereby captures and abuses the other partner. In some ways, family violence is evidence of how fragile
a thing is innocent human trust.
That is why the victims of family violence are so confused -- and confusing -- to medicine. Most of us are aware, in our own
family lives, of how fragile the relationships are between parent and child, child and child, parent and grandparent, and
so on. Whether we do it consciously or not, we are all working with different degrees of success to make those relationships
loving and protective. Hence, when we see the victims of a breach of that trust, we ourselves feel the threat and the disgust
and the bewilderment.
We don't like family violence. We don't appreciate the way it mocks all our notions of what life ought to be like.
It denies the whole concept of human bonding. It turns the mechanism of access for affection into access for injury, and we
all sense our own vulnerability to that particular perversion.
I have dwelt some time on the implications of the definition of "family," since it is a perplexing problem for medicine,
social services, government, and law. Equally perplexing is the definition of "violence," and I want to spend just
a moment on that.
Over the past decade or so, this country has built up an unhappy record of family violence in its many forms. We think of
violence most often as acts of extreme physical force. But both the dictionary and the medical records show many variations
on the theme of injury, which is the result of violence.
Generally speaking, there are four kinds of violence and classes of injury associated with family:
There is, of course, physical violence. This would include not only the willful infliction of pain or injury, but also the
withholding of foods, medicines, and clothing from another family member. It may involve harsh discipline, such as the use
of physical restraints, or it may involve unreasonable confinement or imprisonment, such as in a closet or basement storage
locker. That would come under general heading of physical violence in injury.
Then there is violence and injury of a psychological nature. These include taunts and threats . . . insults . . . condemnation
. . . ridicule. It is the kind of verbal hostility that engender fear and profound emotional withdrawal and breakdown. This
kind of psychological abuse is intended to compromise and eventually destroy the mental health of the victim.
The third kind of sexual violence. This combines both physical and mental injury. The impact is greatest when the victim is
in early adolescence. The effects remain right through the victim's adult life. But sexual violence -- the rape of a child
or an adult -- is profoundly repugnant in civilized society. When rape is committed within the context of the family, however,
is especially frightening, since it is the most vicious kind of denial of the covenant of the family.
The fourth category would be injury or abuse that is material or financial. This may be less a concern for the family physician,
except that it is showing up more and more and we need to include it if we want to understand the total context of family
This form of injury -- or violation, if you will -- is most commonly exercised against elderly parents by their middle-aged
children or against young children by parents. It shuts off any hope of escape or release from an intolerable home, since
the wherewithal of escape -- the ability to "buy one's freedom" -- is systematically taken away.
Family physicians ought to understand and recognize these kinds of violence, when evidence appears among their patients. At
the same time, family physicians should share their own knowledge of the manifestations of family violence with emergency
room personnel, social service and mental health personnel, and other health care professionals in the community. In this
way, it may be possible to improve our reporting methods, which are still quite crude in the area of family violence, and
-- most important of all -- we may be able to save many more lives that would otherwise be compromised if not actually destroyed
by someone within the family.
It had been my original intention to deal with these two definitional problems -- of the "family" and of "violence"
-- and then retreat from the podium. But in the past couple of weeks, the Public Health Service has been challenged on an
issue that is directly related to family violence and I want to mention it today.
There is an influence in our society that has gained rather easy access to the families of America. It is television. And,
using the terms of the definition I offered a few minutes ago, I think television has to a great extent violated the trust
that forms the basis of that access.
In 1972, the Surgeon General's Scientific Advisory Committee on Television and Social Behavior published this now famous
report called Television and Growing up: The Impact of Televised Violence. Dr. Jesse Steinfeld with the Surgeon General at
the time and he deserves to be remembered for his leadership in this project.
The 1972 report concluded with unanimous feeling among the committee that "There is a convergence of the fairly substantial,
experimental evidence for short-run causation of aggression among some children by viewing violence on the screen." It
was a cautious but no less significant statement at that time.
The Committee also concluded, with even more caution, that there was "much less certain evidence from field studies that
extensive violence-viewing precedes some long-run manifestations of aggressive behavior." The Committee acknowledged,
in what might be called a "traditional coda," that "a great deal of research remains to be done."
That report stimulated a great deal of research activity by government and by the academic community into the relationship
between TV viewing and violence. In fact, of all the published research on the influence of TV in this country, better than
80 percent of the work has been done in the last 10 years.
In late 1979, Surgeon General Julius Richmond asked the National Institute of Mental Health to take a critical look at the
volume of research that had appeared since 1972 report. Heading the project with Dr. David Pearl, Chief of the Behavioral
Sciences Research Branch at NIMH. The new findings were published in 1982 in a two-volume report titled Television and Behavior:
Ten Years of Scientific Progress and Implications for the Eighties.
Earlier this month, Dr. Pearl was invited to Capitol Hill to testify on the subject of "Crime and Violence in the Media."
He told Chairman William Hughes and other members of the House Subcommittee on Crime with the 1982 report showed "that
the convergence of findings from a sizable number of studies, on balance, supported the inference of a causal connection between
televised violence and later aggressive behavior." Dr. Pearl said that "The conclusions reached in the 1972 Surgeon
General's Report does have been strengthened by the more recent research . . . "
What has particularly depressed me is the fact that the major networks did not rise to the challenge of the 1972 report and,
in fact, have resisted the implications of the 1982 report. Further, one network, ABC, published a pamphlet earlier this year
that tries to refute the conclusions the 1982 report. It does not succeed.
I won't take your time today with the dreary recital of the research that points such a direct and accusing finger at
television programming for the baggage of violence and aggressive behavior it delivers every day to the homes and families
of America. Nor will I rummage through the dreadful basket of alleged research analyses done by ABC. Their pamphlet is an
embarrassment to the social science research community as well as to the media.
But I think it is time for the networks and for individual stations to be candid with themselves and with the American people.
They dwell far too much on the dark side of human nature for a number of unpardonable reasons: it is sensational . . . it
is easy to do . . . it can be done quickly and cheaply by writers and producers of little talent . . . and requires no sympathetic
knowledge of the human spirit.
Oddly enough, I think the greatest success on TV -- "M*A*S*H" -- also demonstrated how poverty-stricken television
is for talent and decency, since there is no other program like it . . . unless you count reruns of "M*A*S*H." But
here is a series that has gone on for years . . . that remains exceptionally popular . . . and yet it demonstrates clearly,
week after week, a distaste for violence, a sympathetic attitude toward the victims of violence of whatever race, and a preference
for individuals who have the capacity to care for another human being. And the American viewing audience loved it.
But "M*A*S*H" took only one half-hour in about 120 hours of TV each week. I just wish that the networks would spend
more of their resources to improve on that ratio and less of their resources foolishly attacking a respectable piece of research
analysis by NIMH. Isn't that a shame? I think it is.
That's all I want to say about that. But I think we need to be on the record for it. The NIMH studies are good ones and
I support the work they do. And I appeal to our friends in the media to take a second look at their programming and then ask
themselves, "Are we helping the American family avoid violence and defend itself from abuse, or are we pandering to those
At the beginning of his novel, Anna Karenina, Leo Tolstoy wrote, "Happy families are all alike, but every unhappy family
is unhappy in its own way." Try as we might see some patterns of family violence from which we might generalize, I'm
afraid that the Tolstoy equation is correct.
That makes the role of the family physician so much more important. I would hope that each of you, in your professional life
as well as in your personal life, will be sensitive to the ways in which families collapse . . . implode upon their own members
. . . the way a father or a sibling may wreak violence upon another family member . . . that you will sense these possibilities
and find ways, through the medical and social services network at your station, base, or post to prevent the violence and
injury from taking place.
In the course of normal practice, most physicians do not have the opportunity very often of actually saving a life. But in
this particular arena, the life-saving opportunities are there. I hope you will see them and seize them.