The Price of Abuse

A high percentage of hospital emergency rooms around the country treat abuse victims’ everyday, many of whom suffer from severe injuries as a direct result of spousal battering, child maltreatment, elderly abuse, or other types of family violence.

Many victims of battering and abuse receive treatment through primary care providers or family clinics. Some victims’ injuries are serious enough to require hospitalization, or even result in death.

In all, hundreds of thousands of women, children, elderly, and men are injured through mistreatment and violence within the family each year, necessitating medical attention.

The cost of providing medical services to domestic crimes victims can truly be staggering.

According to a study conducted at the Rush Medical Center in Chicago, the average charge for medical treatment given to many abused women, children, and elderly victims was $1,633 per person each year. Nationally, this adds up to an annual total cost of more than $857 million.

In spite of such figures, many believe the totals would be much higher were more victims of family violence and child abuse identified, recognized, reported, treated, and properly diagnosed.

A national health promotion objective for the year 2000 was for no less than 90 percent of the hospital emergency room departments to have plans in place for routinely identifying, treating, and referring victims of family violence and sexual assault.

What follows are some findings with respect to injuries and medical treatment related to domestic violence and child maltreatment:

     * Around half the victims of domestic violence report an injury of a physical Nature.

     * One in ten women beaten by an intimate seeks some kind of medical attention.

      * One in five injured female victims of violence committed by an intimate seeks medical treatment.

* Three in ten injured women in emergency departments were identified as having injuries sustained from domestic violence.

 * More than eight in ten of those seeking medical treatment from an intentional injury perpetrated by an intimate are women.

* About half of such injured victims of intimate violence are treated for bruises or similar type trauma.

* Nearly three in ten injured women in an emergency department as a result of domestic violence required hospital admission; 13% percent needed major medical treatment.

 * Four in ten severely injured battered women in emergency departments required previous medical treatment due to intimate violence.

     * One in four injured patients in emergency departments, as a result of violence, were victimized by a family member or intimate.

* Nearly four in ten female victims of violence in emergency departments were injured by a spouse, ex-spouse, or boyfriend.

* More than half the child emergency department patients under age 12 were injured by a family member.

     * Nearly four in ten emergency department sexual abuse cases involving children younger than 12 are family child sexual abuse cases.

Intimate Violence Injuries & Treatment in Hospitals and Emergency Room Departments

Violence by intimates resulting in hospital emergency department (ED) treatment for injuries sustained by the victim has reached epidemic proportions.

In 2010, the most recent year in which comprehensive data are available, an estimated 2.1 million people were treated in EDs for nonfatal injuries related to interpersonal violence up from 1.4 million .

In 1994 (see Table 4-1). Three-fifths of the injured were males and around half were under the age of 25.

Just over half of all persons injured by violence in the ED were white. Black ED patients treated for injuries caused by violent acts were overrepresented relative to their population figures.

Among the injured patients, 17 percent were victims of violence perpetrated by intimates, such as spouses, ex-spouses, boyfriends, girlfriends, or ex-partners.I4 Women were significantly more likely than men to be treated for injuries caused by an intimate. The number of persons treated in EDs for injuries perpetrated by intimates was estimated at 4 times greater than estimates from the National Crime Victimization Survey.

Table 4-2 reflects the number of injury cases treated in hospital EDs by type of violence and sex of victim in1994. Women injured by intimates comprised around 1 in 5 visits to EDs as a result of intentional violence.

Females were more than 5 times as likely as males to be treated for intimate violence-related injuries.

Although females represented 39 percent of all hospital ED visits as a result of injuries arising from violence, they accounted for 84 percent of the persons being treated for injuries brought on by intimates in 1994.

The patient-offender relationship in injuries sustained through violence, by the sex of the ED patient in 1994, can be seen in Table 4-3.

Nearly 37 percent of female ED patients’ violence-related injuries were inflicted by a spouse, ex-spouse, boyfriend, or ex-boyfriend.

Comparatively, less than 5 percent of the male ED patients injured by violence were victims of someone they were intimately involved with. Women patients were nearly 6 times as likely as men patients to have been injured by a spouse or ex-spouse, and almost 5 times more likely to have injuries committed by a significant other, such as a boyfriend or ex-boyfriend.

Research on the relationship between class and spouse abuse has shown mixed results, while reflecting the prevalence of domestic violence across class lines.

G. Levinger found in a study of couples seeking divorce that intimate violence was reported most often among lower class women.

M. Bulcroft and Straus found spouse abuse for females and males to be higher in the working class than in the middle class.

Other research has suggested that spousal violence may be as prevalent, if not higher, in the middle and upper classes as in the lower classes.

Table 4-4 shows the general characteristics of injuries through violence treated at hospital EDs in 1994.

Approximately one-third of injuries received by patients were bruises or similar type injuries. Nearly another one-third of patients were victims of cuts, stab wounds, or internal injuries.

Around one-sixth of the injured were treated for muscular or skeletal injuries such as sprains, fractures, dislocations, or dental injuries. About one-tenth of the ED injuries were for gunshot wounds or sexual assaults.

In nearly 60 percent of injuries, there was no weapon used. Most patients were injured by being punched or kicked; others suffered falls during attacks or by being thrown into a wall, an object, or to the ground, etc.

When a weapon was used, it was most likely something other than a firearm.

In nearly 19 percent of the injuries, another object was used by the offender. Just over 4 percent of the injuries came as a result of a firearm.

A comparison of data on ED victims of intimate violence and violence by no intimates, by the victim’s age, weapon used to inflict violence, and type of injury in 1994, can be found in Table 4-5.

According to the data from the National Electronic Injury Surveillance System, based on a national sample of hospital EDs, around 1 in 4 of the injuries caused by intentional violence was committed by an intimate.

Most victims of intimate violence fell between the ages of 20 and 45, while no intimate victims were more evenly spread between the ages of 13 to 45.

In nearly 3 in 4 cases of ED patients injured from intimate violence, there was no weapon used, compared to around 6 in 10 violent incidents involving no intimates. Knives, sharp objects, bats, and other objects were used most often as weapons for both intimates and no intimates who were injured; however, the proportion was lower for intimates.

Non-intimates were more than 3 times a likely to be victims of a firearm than intimate victims of violence.

Almost half the persons treated for intimate violence suffered from bruises, with around one fourth of the injuries cuts, stab wounds, or internal injuries.

Approximately one-third of injuries sustained by nonintimates were bruises, and another one-third cuts, stab wounds, and internal injuries.

Slightly more than half the victims of intimate and nonintimate violence were treated for head or facial injuries. Nearly l in 5 intimate ED victims were treated for hand or arm injuries, and around 1 in 10 were injured in the upper trunk area.

A similar pattern existed for victims of nonintimate violence.

Nearly 3 in 10 violence-related injuries of ED patients occurred at home. Less than 1 in 5 took place in stores, offices, or factories; while just under 1 in 10 took place in the street.

The month in which violence resulting in injuries occurred was fairly evenly distributed across the 12 months, with the peak months being June through September – each accounting for more than 9 percent of the violence-related injuries experienced by ED patients.

More than 14 percent of injuries sustained by ED patients involved illegal drugs or alcohol. This was true for nearly 17 percent of the male patients and over 10 percent of the female patients.

Studies show that there is a high incidence of substance abuse in domestic violence situations.

Family Violence Injuries Treated in Hospital Emergency Departments

Family violence and child abuses are responsible for thousands of injuries being treated annually at hospital emergency departments nationwide. The relationship between ED patients injured through violence and the perpetrator of such violence in 1994 is shown in Table 4-6. A family member such as spouse, parent, child, sibling, or other relative were responsible for an estimated 15 percent of all intentional or possibly intentionally perpetrated injuries. A parent was more than 3 times as likely to have injured a child ED patient than the other way around. Boyfriends, girlfriends, or former intimates were the offenders in almost 10 percent of the violence-related injuries sustained by ED patients.

Children under the age of 12 treated in emergency departments for injuries caused by violence were far more likely to have been injured by a relative than a stranger, as seen in Table 4-7. More than 56 percent of the child patients younger than 12 received injuries from a relative, thus illustrating the significant relationship between child abuse and injuries to the victim requiring ED treatment. Just over 34 percent of the perpetrators of violence-related child injuries were acquaintances, while less than 10 percent of the injuries were caused by a stranger.

ED teenage patients were injured by relatives in less than 12 percent of the cases, while more than 58 percent were victims of violence by acquaintances. More than 20 percent of adult patients age 20 and over received violence-related injuries from a relative, while nearly 44 percent were victimized by acquaintances.

Table 4-8 indicates the type of offense in violence-related injuries treated in hospital EDs, by age of patient, in 1994. Most patients among all age groups were most likely to be treated for injuries arising from assaults. Around 30 percent of the teenage and adult patient assault victimizations involved fights or altercations, compared to fewer than 10 percent of the child patients under age 12.

Young children were far more likely than teenagers or adults to be treated for suspected or confirmed rape or sexual assault. More than 29 percent of the injuries suffered by ED child patients under 12 were for rape or sexual assault, while less than 5 percent of the teen injuries and under 3 percent of the adult injuries were a reflection of sexual assaults of any kind.

Of the children younger than 12 receiving ED treatment in 1994, half of those being treated for sexual abuse were age 4 and under, while half the child patients receiving treatment for other types of violence-related injuries were age 5 or under. In 39 percent of the rape and sexual abuse cases involving children under the age of 12, the patients were brought to the ED by parents or guardians who suspected the child may have been sexually abused or assaulted.

Identifying Family Violence Victims

The evidence suggests that many victims of domestic violence and child abuse are not being identified by physicians and other medical staff during examination or treatment.

Consider the following findings; this is from the year 2000:

     * Ninety-two percent of battered women do not discuss the domestic violence with their physicians.

     * In 40 percent of cases in a study of battered women being treated in a hospital emergency department, physicians failed to discuss the battering with the patients.

     * In a study of women at a family clinic, nearly 23 percent reported being physically abused by an intimate within the past year, with a lifetime rate of battering at around 39 percent. Only 6 of the 394 women surveyed had ever been questioned by their physician about domestic violence.

     * In one study of a metropolitan emergency department with a protocol for domestic violence, the ED physician did not get a psychosocial history from the battered woman, ask about abuse, or inquire concerning the victim’s safety in 92 percent of the cases of domestic violence.

     * A high percentage of abused elderly victims’ clinical symptoms are misdiagnosed as due to aging.

     * Most battered parents do not admit being abused by their progeny to physicians or others.

     * A national study of 143 accredited medical schools in the United States and Canada found that 53 percent of the schools did not require medical students to be educated about domestic violence.

Other studies have supported the lack of preparedness, education, ability to recognize, and indifference of many physicians, other hospital staff, and medical schools with respect to domestic crimes and family violence.

In a recent survey of hospital personnel, it was found that less than 5 percent of the evidence of domestic violence was recognized in women patients.

In another study of the prevalence of domestic violence among an inpatient female population at a nontrauma urban teaching hospital, 26 percent of the respondents reported ever being in a violent relationship.

Not one of the 181 patients, ages 18 to 60, were asked by hospital staff about domestic violence or victimization by an intimate.

Of great concern is the inadequate training of medical students on domestic violence and its dynamics. In a survey of medical school education regarding domestic violence sent to member schools of the Association of American Medical Colleges, 53 percent of the schools that responded gave no instruction to students concerning domestic violence. Forty-two percent had at least one required course on the subject, while 5 percent of the colleges reported that there are elective courses available containing information on domestic violence.

Child Abuse Related Injuries

Child abuse victims are also at risk for non-detection or misdiagnosis of injuries as a result of child abuse or neglect. Many children being treated in hospitals and clinics across the country have abuse-related injuries that are being misidentified or unrecognized as to their cause.

Young children are especially susceptible to sustaining injuries due to child abuse that may be overlooked or given the wrong diagnosis by medical workers.

“Because diagnostic reasoning is often shaped by the history provided” of an abused child patient, usually by the parent or guardian, “a misleading history can misdirect the diagnostic process and result in an incorrect diagnosis.”

In a study of fractures in 52 abused children under 3 years of age, in only 1 instance did a parent initially report a case of child abuse.”

In nearly 9 out of 10 cases the most common victims’ history as reported by the parent or caretaker was a fall or abnormality, such as a seizure, in explaining the fracture or sibling abuse.

Another study of undetected maltreatment found that in nearly one-third of the cases of head injuries in toddlers and babies caused by child abuse, doctors failed to notice the injuries.” This was particularly true when such injuries occurred in white children from two-parent households.

The study found that doctors even failed to detect life threatening problems such as brain hemorrhaging and skull fractures. The researchers contended that 80 percent of the child fatality victims of injuries due to child maltreatment might have lived had the abuse been recognized sooner.

Supporting these findings of misidentification of child abuse are two other studies.

In C. Jenny and colleagues’ analysis of a study on doctors’ failure to recognize head injuries caused by child abuse, it was found that nearly 1 in 3 children under the age of 3 with a final diagnosis of child abuse related head injury had visited a physician at least once previously and there had been a misdiagnosis of the injuries.

Twenty-eight of the victims were reinjured as a result and 4 child deaths may have been averted with an earlier correct diagnosis.

The National Committee to Prevent Child Abuse found that 41 percent of abused children who died between 1995 and 1997 had been seen by staff from child protective services agencies.

Reflecting on the misconceptions about child abuse with respect to the socio-economics and race factors, the study reported that physicians frequently misdiagnosed abuse in nearly 40 percent of head injury cases due to child maltreatment in white children or children from two-parent families, while not identifying the abuse in around 20 percent of cases involving minority children or children living in single parent homes.

Elder Abuse Related Injuries

Similar to child victims of abuse, elderly abuse victims are vulnerable to an incorrect or improper diagnosis by physicians of injuries due to familial or custodial abuse or neglect.

Clinicians for elderly patients frequently ignore signs of maltreatment often “attributable to the normal process of aging.

Recurrent fractures, for instance, may be automatically ascribed to the brittle bones of osteoporosis. Malnourishment may be attributed to the nutritional problems and poor appetite that often accompany old age.

This unfortunate misinterpretation of elderly victimization, along with the difficulty in getting victims to report abuse, makes it all the more critical for medical personnel to be able to recognize and treat such maltreatment for what it is.

The same sense of urgency holds true for properly diagnosing all forms of family violence.

More education and training is needed across the board in the medical community in understanding and identifying familial and intimate-related battering and sexual abuse, asking the right questions of victims, reporting suspected cases of violence in the home to authorities, and properly diagnosing and treating domestic violence, child abuse, and elderly abuse victims.


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