National Physician Resource Center for the Prevention of Family Violence and Victimization: Charge, Chicago, Illinois
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37 (813,133 Bytes)
1989-10-05 (October 5, 1989)
Koop, C. Everett
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Medical Subject Headings (MeSH):
Reproduction and Family Health
"National Physician Resource Center for the Prevention of Family Violence and Victimization: Charge, Chicago, Illinois"
Box Number: 9
Folder Number: 1989 Oct 5
"National Physician Resource Center for the Prevention of Family Violence and Victimization."
October 5, 1989
Charge C. Everett Koop
In 1870 the United States Congress passed a law creating an organization to prevent cruelty to animals. Very quickly, even
a relatively small towns, organizations began to protect all manner of furry or feathered creatures. It is a sad commentary
on our society to admit that it took an additional 100 years to create our first shelter for battered women. Violence is not
only a problem for American society, but also it has become a plague, a rapidly expanding health problem.
My interest in this issue began in a curious way. In 1984, I was asked to address a meeting on television violence. The government
had been funding research in TV violence for the past 20 years and speeches on the subject by the Surgeon General were rather
routine . . .
But I began to wonder if somehow our preoccupation with TV violence might actually be preventing us from seeing the larger
and much more serious problem of real violence in our society. Even a quick glance at the problem revealed its staggering
Reports from around the nation indicated that as many as 4 million children were victims of abuse and neglect.
To our shame we had hidden this national tragedy.
For example, it would appear that the greatest threat to children is a flight of stairs . . . any flight of stairs.
I heard it over and over again when I was Surgeon-in-Chief at Children's Hospital of Philadelphia. Children were brought
in with severe fractures, sprains, concussions, and contusions. And we were told by parents or guardians that the child "fell
down the stairs."
And we in the medical profession put that down on the record so we relayed that information to state and national data collections
and, sure enough, after all the reports are in from all over the country, we discover that the biggest threat to children
is the nearest flight of stairs.
But those of us in child protection and in child health know the awful truth. We know that some children may fall down stairs
. . . but they are probably a small minority. Many of those young victims have been punched . . . slapped . . . thrown . .
. and beaten with fists, clubs, and other weapons.
Adults do that to children. Stairs do not produce the familiar physical signs of abuse. For centuries adults have injured
children . . . and have lied about it . . . and other adults have heard those lies and then merely turned away.
The statistics for women are equally alarming. Estimates vary, but we know that from 1 to 3 million women in the United States
are battered and assaulted each year by their husbands or partners. Many are raped. These women victims of assault are permanently
injured -- not just physically but also mentally -- while some of them lose their lives.
In the US an estimated 40% of all women experience some type of sexual abuse as children. As many as 44% of adult women reported
completed or attempted rape, including rape by their husbands or other family members.
Battery is the single most significant cause of injury to women in this country. One out of every five women seen in hospital
emergency rooms is a victim of personal injury caused by spouse abuse. These injuries including bruises, concussions, broken
bones and teeth, throat injuries, lacerations and stab wounds, burns, and bites. The wounds are inflicted by being struck
by fists and other blunt objects and by being thrown down stairs. It is not a pretty picture.
I tend to think of Nevada as a rather peaceful state. In 1985 lawmakers passed a bill allowing victims of domestic violence
to get emergency restraining orders to protect them from their partners, regardless of marital status. At the time, no one
saw a great need. They were inundated, and still are in Reno.
Remember, behind these cold numbers, percentages, and statistics are real people, our neighbors, our family members, our fellow
The consequences are enormous -- Loss of self-esteem, inability to work productively and to care for children, psychiatric
problems, alcohol and drug dependence.
Studies have shown that battered women are four to five times more likely than non-battered women to require psychiatric treatment.
Many suffer from anxiety, increased levels of hostility, obsessive-compulsive symptoms, and agoraphobia - fear of open spaces.
Some commit suicide. Moreover, studies have shown that women who are abused are eight times more likely to abuse their children
than women who are not abuse. These abused children then often become abusers themselves.
We realize that we don't have good statistics in this difficult area. But, if anything, these numbers are much too low.
We estimate, for example, that for every adult victim of violence counted by the police and the FBI, as many as three additional
adult victim's pastor hospital emergency rooms or community clinics and are missed by the police altogether.
What is the impact on the nation of this plague of violence? Can we really measure it? For example, what is the impact on
our society of 150,000 rapes a year? What is the real impact of nearly 1.3 million robberies involving violence and weapons?
And what is the impact of five million cases of simple and aggravated assault?
It's an overwhelming moral, economic, and public health burden that our society can no longer bear. In this country, no
man has a license to beat . . . and get away with it. And no woman is obliged to accept a beating . . . and suffer because
As I looked at this compelling issue it became obvious to me that violence is not only a problem for law enforcement and social
science. Violence was also a health issue. And violence was having an overwhelming impact upon the nation's health care
Early in my career as Surgeon General, I tested out these concerns in a speech before the American Academy of Pediatrics.
And again in a presentation at the Western Psychiatric Institute at the University of Pittsburgh.
With both groups I struck a responsive chord. Therefore, in 1984, I concluded that we ought to move ahead and address the
larger issue of domestic violence as a public health issue and put aside for a while the narrower, sub-set of TV violence.
By tackling violence is a public health issue I wanted not only to save the lives of potential victims . . . mainly women,
children, and old people . . . but also even to prevent additional violence from happening.
The next step, over five years ago, was to bring together some 170 experts for three days in Leesburg, Virginia to determine
how the health professions we provide better care for victims of violence and also how they might contribute to the prevention
It was clear that the medicine, nursing, psychology, and social service professions have been slow to develop a response to
violence that formed an integral part of their daily professional life. Too often our health professionals continued to indulge
compartmentalization . . . the vertical separation of one life-saving service or discipline from all others.
It's frustrating habit we've developed, but one which we at that Leesburg meeting agreed should be ended as soon as
possible and as effectively as possible.
We encouraged health professionals in each community in the nation to develop a multi-disciplinary approach to the problem
of violence as a health issue. We realized we needed a clear plan of action, not just another position paper or flight of
The resulting report from the 1985 "Surgeon General's Workshop on Violence and Public Health" offered 153 recommendations
on issues including rape and sexual assault, other physical assaults, homicide and spouse abuse. We also set objectives for
the development and implementation of plans for routinely collecting data on the number, rate and characteristics of morbidity
associated with a variety of facets of violent and abusive behavior, including spouse abuse.
Another proposed objective called for 90% of hospital emergency departments to have protocols for routinely identifying, treating
and properly referring victims of spouse abuse -- including unmarried partners, dating relationships and pregnant women who
are abused -- as well as victims of sexual assault.
A subsequent "Surgeon General's Letter on Child Sexual Abuse", and a public service announcement on spouse abuse
urged the medical profession to Gilmour candidly and directly with this issue of domestic violence. These and other publications
-- and meetings like this -- will help physicians sort through the problems not only diagnosis and treatment of family violence,
but also enable them to find their way through the necessary reporting procedures, and even possible involvement in the courts.
We need not only to identify the perpetrators of abuse, but also to provide scientific sorting procedures for innocent people
wrongly accused of sexual abuse.
Help is available from law enforcement and the courts . . . from community and social service organizations, such as local
and state alliances against domestic violence . . . and now from medicine.
The health profession must play a greater role and go beyond mere treatment of injuries and symptoms. They must actively identify
cases of abuse and battery for what they are, report them to authorities, refer cases to law enforcement officials, or social
service agencies or private groups to assure that people at great risk our protected.
We are already moving in the right direction. For example, the American College of Obstetricians and Gynecologists has come
forward with an excellent information and education program for its own members.
And now today we have come to the American Medical Association's "National Physician Resource Center for the Prevention
of Family Violence and Victimization."
But there is still so much to do: We need more data. While we might feel we have learned enough from research and experience
to move forward into action, there are still many areas, especially in the field of human behavior, where we could use more
specific information based on good research and demonstrations.
What are the most important mechanisms for ensuring attention to significant public health problem is to adequately document
its incidence. It is necessary not only to define all aspects of the problem through the collection of relevant and corrected
data, but also to analyze those data in order to define interventions and then to measure the impact of those interventions
so we can determine what works. Such data are essential to secure resources for research, for educational efforts, and for
intervention programs to help the abusers well is the victim.
Just as we have worked, using data, to make smoking an unacceptable behavior, we must also work to make violence of any kind
unacceptable behavior. It is important that our efforts be continued and sustained and not episodic in response to particular
reports of violence that horrify us.
Physicians must play a central role in this national campaign against violence, not only to alleviate the pain and suffering
of the individual, but also to reduce the significant drain on scarce and increasingly more expensive health services for
injury that should not have occurred in the first place. We know from looking at records and hospital emergency rooms that
the victims of rape and sexual abuse return again and again to their hospitals, clinics, or family physicians with an endless
history of chronic complaints: neurological, cardiovascular, genitourinary, psychological. These complaints are not imagined.
They are very real and require medical care. And they are more than likely the direct results of that original trauma.
What physicians need now and what the country needs now is action.
Our recommendations, then, ought to be framed in such clear, direct language that our colleagues in medicine, nursing, psychology,
and social service anywhere in the country can absorb them, understand them, and put them into practice.
To say were in favor of a multidisciplinary approach and leave it at that is obviously not enough. We need to make such recommendations
for all the health services . . . how they might be organized, how they should interact, how they ought to respond to the
needs of victims of violence, and how they should contribute to the prevention of violence. We need to isolate those current
multidisciplinary programs that seem to work . . . and then show how they can be replicated in any community or institution
in this country, without delay.
We say we are civilized society. All right, let's act like one.