Family violence is a major public health problem in the United States. It leads to physical and psychological disability, death and loss of productivity. It can perpetuate itself through successive generations and contributes to the escalating health care costs in this country. Family violence affects a significant proportion of the US population either as direct victims or as witnesses of abuse.
Family violence constitutes a triad encompassing domestic violence ("intimate partner violence"), child abuse, and elder abuse. These problems can exist independently or in combination in the same household. Studies indicate that child abuse occurs in 33 percent to 77 percent of families in which there is abuse of adults.2, 3, 4 Between 3.3 and 10 million children witness domestic violence each year.5, 6 Children whose mothers are abused may experience serious emotional distress and manifest severe behavioral problems as a result.2, 4
Family violence is prevalent in our society. In 1999, there were 826,000 cases of documented child abuse or 11.8/1000 children. The highest rate of abuse was noted in those aged 0 to 3. There were 1100 deaths due to abuse and neglect or 1.62/100,000 children. Data indicates that 42.6 percent of these children were less than one year of age and 86.1 percent were less than six years of age.7 It has been estimated that failure to diagnose an initial presentation of child abuse may result in a 30 percent to 50 percent chance of repeated abuse and a 5 percent to 10 percent chance of death.8
An estimated 2.5 million women and 1.6 million men are physically assaulted by an intimate partner annually in the United States. Thirty percent of women and 37 percent of men receive medical care for their injuries.9 A report based on statistics from a nationally representative sample of hospital emergency departments revealed that 36.8 percent of female patients and 4.5 percent of male patients who had been treated for violence-related injuries had been injured by current of former intimate partners.10 Intimate partner violence can also result in complaints of chronic pain and somatizing disorders brought on by the stress of living in a violent environment.11 Therefore, orthopaedic surgeons may be called upon to treat victims of family violence in both emergency and non-emergency settings. The number of patients presenting to the offices and clinics of orthopaedic surgeons is unknown and unstudied.
The National Center on Elder Abuse estimated that in 1996 there were 1 to 2 million elderly persons in this country who experienced abuse or neglect. Women made up 58 percent of victims. Two-thirds of the perpetrators of abuse were family members who acted as caretakers.12
The American Academy of Orthopaedic Surgeons (AAOS) believes family violence, in the form of child abuse, adult domestic violence and elder abuse, is a major public health problem in the United States. The Academy is committed to providing appropriate care to victims of family violence whether they present to an emergency department, orthopaedic office/clinic.
The AAOS endorses the following principles for orthopaedic surgeons regarding family violence:
- Orthopaedic surgeons should become familiar with the fact that family violence victims present for orthopaedic care to both emergency and office/clinic settings.
- Orthopaedic surgeons should become knowledgeable about the diagnosis and treatment of family violence and should learn what resources are available in the community for referral of victims.
- Orthopaedic surgeons should become familiar with and adhere to applicable abuse reporting laws and other legal requirements, as well as appropriate procedures for dealing with and referring suspected cases of abuse.
- Orthopaedic surgeons should put into place protocols in their offices/clinics for dealing with victims of family violence. These protocols should include:
- Identification of victims
- Documentation of findings
- Treatment of injuries or conditions
- Assessment of the immediate safety of the patient
- Referral to community family violence resources and/or reporting to appropriate agencies as dictated by state statues.
- Orthopaedic surgeons should have an awareness of the possibility of family violence as a contributing factor when interviewing patients who present with traumatic injuries or chronic pain conditions. If a high index of suspicion is developed, in depth questioning should be performed and appropriate steps taken as described above.
The AAOS believes that orthopaedic surgeons should become aware of and comply with state and/or local reporting laws. The AAOS also believe that in cases of adult domestic violence, reports should only be made with the knowledge and consent of the victim, unless required by law, to reduce the probability of future harm to the victim.
|1.||National Institute of Justice: Victims costs and consequences, a new look. Washington, D.C., 1996.|
|2.||Garbarino J, Kostelny, Dubrow N: What children tell us about living in danger. Am Psychol. 46:376-83, 1991.|
|3.||Wright RJ, Wright RO, Isaac NE: Response to battered mothers in the pediatric emergency department: a call for an interdisciplinary approach to family violence. Pediatrics. 99:186-92, 1995.|
|4.||Zuckerman B, Augustyn M, Groves BM, Parker S: Silent victims revisited: the special case of domestic violence. Pediatrics. 96:511-13, 1995.|
|5.||Gelles RJ. Family Violence, 2d ed. Newbury Park: Sage Publications, 1987:82.|
|6.||Straus MA, Gelles RJ: Physical violence in American families. New Brunswick, NJ: Transaction publishers, 1990.|
|7.||US Department of Health and Human Services: Child Maltreatment 1999: Reports from the states to the National Child Abuse and Neglect Data System. US Government Printing Office, Washington, DC, 2001.|
|8.||McClain PW, Sacks JJ, Froehlke RG, Ewigman BG: Estimates of fatal child abuse and neglect, United States, 1979-1988. Pediatrics 91:338-43, 1993.|
|9.||US Department of Justice: Full Report of the Prevalence, Incidence and Consequences of Violence Against Women. 2000.|
|10.||US Department of Justice, Bureau of Justice Statistics: Violence-related injuries treated in hospital emergency departments. August, 1997.|
|11.||Eisenstat SA, Bancroft L: Domestic violence. N Engl J Med. 341:886-92, 1999.|
|12.||National Center on Elder Abuse, American Public Welfare Association: National Elder Abuse Incidence Study, 1996. (c) February 2002 American Academy of Orthopaedic Surgeons This material may not be modified without the express written permission of the American Academy of Orthopaedic Surgeons. Document Number: 1020|
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