. . . the following kinds of research ought to be pursued:
. How is the health care system actually used by victims of violence?
. What are the salient characteristics of assault and homicide victims,

and what are the circumstances of each incident?
. What kinds of discrepancies are there between hospital and police

reports of assault?

. What kind of risks do assault victims run of eventually being killed?
. How effective are current hospital policies and procedures for identi-

fying, coding, treating, and referring victims of assault?

In the area of &wires we recommend that . . .

. organizations representing professionals who provide emergency
health care, such as the American College of Emergency Physicians, the
National Association of Social Workers, and the American Nursing
Association, should review concepts and procedures relative to emergency
care for victims of violence, with particular attention to improving victim
identification, assessment, treatment, and referral. (S-l)

. . evaluation and treatment services should be available to both direct
and indirect victims of homicide and other violence, including witnesses,
care-givers, the victim's family and significant others, and the com-
munity. (S-2)

. . . special attention should be paid to the adequacy and sensitivity of
the health care given to young minority men in low socio-economic
status who are at greatest risk for homicide and repeated assaults. (S-3)

. . . every examination of a direct or indirect victim of violence should
include a history of past victimization and/or perpetration of violence,
the victim's risk profile, and an assessment of his or her total health
needs. (S-4)

. . a comprehensive, collaborative, community-based approach to vic-
tim assistance should be encouraged among health care providers, the
criminal justice system, victim service agencies, churches, and other
relevant community service organizations. (S-5)

. . . leaders in health and mental health should support the development
ofvictim assistance programs where they don't exist and the improvement
of existing programs that are inadequate. (S-6)

. . . health care providers should draw upon the experience of victim
service agencies in the course of improving their own case management,
advocacy, and referral services for victims of violence. (S-7)

. . . the Public Health Service should help in the review and dissemi-

51


nation of innovative hospital protocols offering better care for victims of
violence. (S-8)

. . . hospital boards and top administrators should clearly articulate their
hospital's policy in the following areas affecting the care of victims of
violence:
. a commitment to effective identification, treatment, and referral services;
. a commitment to train staff who interact with direct or indirect victims;
. and the use of multi-disciplinary hospital committees to monitor policy
implementation and maintenance of quality care for victims. (S-9)

ASSAULT AND HOMICIDE: PREVENTION

        CHAIR: John B. Wailer, Jr., DrPH
ADVISORY COMMITTEE MEMBER: Mark L. Rosenberg, MD
        RECORDER: Christine Grant, RN, MSN
       PARTICIPANTS: Lee P. Brown, PhD
            Lynn A. Curtis, PhD
               Ruth E. Dennis, PhD
               Robert A. Fein, PhD
            Karil S. Klingbeil, MSW, ACSW
            Dorothy Otnow Lewis, MD
            J. Ronald Milavsky, PhD
                 Robert Ressler

Vicki Weisfeld, MPH

Members of this work group introduced their recommendations with
the following statements:

. Our specific recommendations for the health and public sectors are
preceded by general policy recommendations that go beyond the health
sector.

. The focus on the health sector recognizes the vital contributions health
professionals can make without implying that those contributions are
any more or any less important than those made by other disciplines.
. We recognize that the Office of the Surgeon General cannot, by itself,
carry out all these recommendations, but we nevertheless believe that
these policy issues are fundamental to any statement on the prevention
of homicide and assaultive behavior.

52


Therefore, in the area of Policy we recommend that . _ .

. . . there be a complete and universal federal ban on the manufacture,
importation, sale, and possession of handguns (except for authorized
police and military personnel) and that the manufacture, distribution,
and sale of other lethal weapons, such as martial arts items, knives, and
bayonets, be regulated.

. . . criminal penalties be levied for possession of any weapon where
alcohol is sold or served.

. . the public should be made aware that alcohol consumption may
also be hazardous to health because of its association with violence.

. a full employment policy should be developed and implemented
for the nation, with immediate attention given to creating jobs for high-
risk youths.

. there be an aggressive policy to reduce racial discrimination and
sexism.

. . the cultural acceptance of violence be decreased by discouraging
corporal punishment at home, forbidding corporal punishment at school,
and abolishing capital punishment by the state - all are models and
sanctions of violence.

. . that there be a decrease in the portrayal of violence and violent role
models on television and other media and an increase in the presentation
of positive, non-violent role models.

In the area of Education we recommend that . . .

. . the education of health professionals should include training in the
identification, treatment, and/or referral of victims, perpetrators, and
persons at high risk for interpersonal violence. (E-5)

In the area of Research we recommend that . . .

. . studies should be conducted to examine how current rates of as-
saultive violence and victimization may be related to the policy of dein-
stitutionalization of mentally ill persons and the lack of adequate
community-based support services for those persons and their families.
(R-3)

. . development should be encouraged of health education demon-
stration projects for the family, school, and community aimed at de-
creasing interpersonal violence and that these projects be evaluated to
their effectiveness and replicability. (R-4)

In the area of Services we recommend that . . .

53


. community health care facilities should offer comprehensive, multi-
disciplinary programs to detect, assess, and treat victims and perpetrators
of all forms of interpersonal violence, as well as to assess and treat family
members and individuals at high risk of violence. (S-10)

. . . health care providers, criminal justice agencies, schools, and social
service agencies should communicate and cooperate to a greater extent
in order to improve the identification and treatment of - and early
intervention for - high-risk individuals. (S- 11)

CHILD ABUSE: EVALUATION AND TREATMENT

           CHAIR: Howard B. Levy, MD
ADVISORY COMMITTEE MEMBER: Robert G. McGovern, MD
            RECORDER: Lawrence T. McGill
       PARTICIPANTS: Douglas J. Besharov
              Capt. Edgar R. Blount, MD
               Jane N. Burnley, PhD
                David L. Chadwick, MD
              Howard Davidson, Esq.
               Peter W. Forsythe
              Nahman Greenberg, MD
                Isadora Hare, MSW, ACSW
                Peter A. Howland, MD, MPH
                 Marie Kanne Poulsen, PhD
              Johanna Schuchert
               George G. Sterne, MD

In the area of Education we recommend that . . .

. . . professionals who work with children and their families should be
offered - and encouraged to take - interdisciplinary continuing ed-
ucation programs. (E-6)

. . . schools that prepare professionals to work with children and families
should adopt interdisciplinary curricula for clinical as well as classroom
instruction in the prevention and treatment of child abuse; persons from
all involved disciplines should share in presenting these curricula to
students. (E-7)

54


In the area of Research we recommend that . . .

. . . local, state, and federal agencies should design and fund child abuse
research and treatment, utilizing a public health perspective. (R-5)

. . individual communities should establish their own multi-profes-
sional "commissions" to assess both harm and benefit to child abuse
victims resulting from criminal prosecution and disposition. (R-6)

. . . a major longitudinal/epidemiological study should be mounted,
similar in purpose and scope to the Framingham and Cambridge studies,
documenting prospectively at least 30 years' experience in the causes,
consequences, and nature of child abuse and responses to it. (R-7)

In the area of Set-Gces we recommend that . _ .

. . . child protection services and other agencies should expand the range
of both long-term and intensive short-term treatment alternatives for
families in need, using such modalities as medical services, family sup-
port, and parent/adult aides. (S-12)

. . visiting nurses, attending physicians, and other professionals should
make their own services more readily available for abused children and
their families, allowing Child Protection Service agencies to focus on
the more serious incidents of abuse and on the children at highest risk.
cs- 13)

. . every hospital should have an interdisciplinary child protection team
that can care for all the child's and family's needs at one site and within
a minimum number of visits. (S-14)

. standards of health care for abused infants and children should
include immediate and complete physical and psychological assessments;
competent and continuous care should be provided for any problems
uncovered in these assessments. (S- 15)

55


CHILD ABUSE: PREVENTION

         CHAIH: Douglas A. Sargent, MD, JD
ADVISORY COMMITTEE MEMBER: Georgia K. Millor, RN, DNS
        REORDER: Helen Rosenberg
       PARTICIPANTS: Laura Anderson, MPH
               Dante Cicchetti, PhD
               Anne H. Cohn, PhD
            Maj. Gloria Deniz, RN, USAF
              Sara Reed DePersio, MD, MPH
                 Suellen Fried

Col. Jesse Harris, DSW
LaVohn Josten, RN, PhD
Blair Justice, PhD
David M. O'Hara, DASS
Barbara Rawn
Reymundo Rodriguez
Gloria Smith, PhD
Robert L. Stein II

In the area of Education we recommend that . . _

. . . public awareness should be dramatically increased regarding the
nature and extent of child abuse, with emphasis on the fact that child
abuse is not limited to physical and psychological abuse but also includes
abusive neglect, poverty, and other social injustice. (E-8)

. a major campaign should be carried out, with the help of the media,
to reduce the public's acceptance of violence in general and violence
against children in particular, including physical punishment (a cam-
paign could use a variety of techniques, such as declaring a "No Hitter
Day"). (E-9)

. the American people should come to understand and agree that
corporal punishment of children should be abolished. (E- 10)

. planning for pregnancy ought to be seen as the starting point for
the prevention of child abuse and other forms of child maltreatment by
new and/or young parents. (E- 11)

. . . education for parenthood should be more widely promoted and
supported so that it may be made available to all prospective and current
parents. (E-12)

. . . public health departments and public hospitals *;ld clinics should

56


provide educational and support services for parents and families, in-
cluding appropriate cultural and linguistic services for particular ethnic
and minority groups. (E-13)

In the area of Research we recommend that . . .

. . studies should be done to identify what makes abusive families
different from non-abusive families. (R-8)

. . . we need to learn more about the ways various ethnic and racial
groups define "abuse. " (R-9)

. . . we learn more about the impact that changes in public policy make
upon the family. (R-10)

. . further development and testing should be done of explanatory and
predictive models for maltreatment causality. (R- 1 I)

. . more multi-disciplinary longitudinal and cross-cultural research be
carried out to evaluate the impact of violence prevention programs on
individual children, families, communities, and ethnic groups. (R- 12)

. . . the Epidemiology of Violence Branch of the PHS Centers for Disease
Control ought to focus more attention upon child abuse and maltreat-
ment. (R- 13)

In the area of Set-r&es we recommend that . . .

. . as a public health priority, families should be provided with vital
services, such as home visitor services, for the health and welfare of
vulnerable children. (S- 16)

. . . priority services - including treatment and rehabilitation - should
be provided to children who are at highest risk to be abused, such as
developmentally disabled children, runaways, and children of parents
who are at highest risk to be abusive, such as prison inmates, teenage
mothers, mentally retarded or otherwise mentahy impaired parents, sub-
stance abusers, homeless parents, and parents who themselves had been
abused as children. (S-17)

. the kind of quality child care that promotes healthy child devel-
opment should be available to all families. (S-18)

. . . those services that prevent undesired pregnancies should be generally
available. (S- 19)

. . children identified as being at greatest risk for abuse should be
afforded linguistically and culturally appropriate services for the preven-
tion of child abuse. (S-20)

. alternatives to abusive behavior should be widely offered, such as
training in conflict resolution, anger control, and stress management

57


and other programs in behavioral change like those offered by self-help
groups. (S-2 1)

. a national public health resource center ought to be established to
train and otherwise assist professionals working on the public health
aspects of child maltreatment; this center would also cooperate with
social service, legal aid, and other types of resource centers dedicated to
child abuse. (S-22)

CHILD SEXUAL ABUSE: EVALUATION AND TREATMENT

         CHAIR: Jean Goodwin, MD, MPH
ADVISORY COMMITTEE MEMBER: Eli H. Newberger, MD
         RECORDER: Laurie Anne Pearlman, MA
       PARTICIPANTS: Jon R. Conte, DSW
               Bruce Cushna, PhD
               Marlene Echohawk, PhD
              Henry Giaretto, PhD
              Ellen F. Greenberg, PhD
              Charles F. Johnson, MD
             Sheldon Levy, PhD, MPH
             Clare Marie Rodgers
               Sandra Rosswork, PhD
              Marti H. Speights
             Joyce N. Thomas, RN, MPH
              Martin Wasserman, MD, JD
              Bruce A. Woodling, MD

In the area of Edurdtion we recommend that . . .

. . . a core curriculum in child sexual abuse should include strategies
for identifying, reporting, assessing, treating, and referring victims and
should be a required part of the professional education of all child abuse
reporters mandated under state law, such as physicians (especially those
in emergency medicine and pediatrics), psychiatrists, psychologists,
nurses, mental health workers, dentists, social workers, teachers, law
enforcement personnel, and clergy. (E- 14)

58


  . . . professional schools and organizations, certifying boards, and in-
stitutional accrediting bodies should cooperate in the development and
implementation of a core curriculum in child sexual abuse. (E-15)

  . . . health, mental health, and criminal justice professionals providing
direct service to victims of child sexual abuse need to be trained in (and
made sensitive to) normal child development, cross-cultural differences,
the special vulnerability of handicapped children, and the many legal
and forensic issues in this area; they also need to be trained in the problem
of trauma contagion, which can cause staff burnout and victim re-trau-
matization. (E-16)

In the area of Resurcb we recommend that . . .

  . . . a national child sexual abuse research and information center should
be established to provide computerized data about funding, ongoing
research, treatment programs, assessment protocols, and training and
educational materials for workers in this field and for families of victims.
(R-14)

  . . a centralized information point within the Department of Health
and Human Services, preferably the Centers for Disease Control, should
be established and made responsible for aggregating, standardizing, and
transmitting case report data; for collecting and analyzing violence-
related data from the FBI, the National Center for Health Statistics, and
the National Institute of Justice; and for conducting surveys of practi-
tioners, institutions, and the public in order to define and report annually
on the incidence, prevalence, time trends, and geographic distribution
of child sexual abuse. (R-15)

. . . studies should be carried out of the short- and long-term impact
of sexual abuse on infant and child victims, with particular attention to
children who are physically, emotionally, or developmentally impaired;
who are victims of extreme abuse; who have minimal family or other
support, particularly children requiring placement; and who have ex-
tensive and intrusive legal problems. (R-16)

. . . baseline data need to be gathered - through standardized tests,
structured interviews, and genital examinations - to determine genital
and psychosexual development among non-abused children for compar-
ison with data from sexually abused children. (R-17)

. . research should be conducted that leads to the further development
of such specialized instruments as symptom checklists, developmental
assessments, projective tests, structured interviews using anatomically


correct dolls, coloring books and drawings, and structured family as-
sessments. (R- 18)

. . more studies in treatment outcomes should be conducted, partic-
ularly in the following areas:
. What happens when either the perperator or the victim in an intra-
familial case of child sexual abuse is removed from the family?

. How effective are individual, group, and family treatment programs
involving sexually abused children?
. What strategies - legal, home care, or patient advocacy, for example
- will bring into treatment the families of sexually abused children?
(R- 19)

In the area of Services we recommend that . . _

. . the assessment of a victim of child sexual abuse and his or her
family should be done by mental health and other experts as part of a
multidisciplinary team, with the primary goal being a treatment and
intervention plan for both victim and family to be carried out with
community resources. (S-23)

. . each disclosure of abuse should lead to only one assessment before
a treatment plan is created and the clients - victim and family - are
referred to community resources. (S-24)

. . assessments should be done with standardized protocols for four
axes (physical health status, mental health status, family and environ-
mental factors, and the investigatory/legal situation), with additional
axes of assessment incorporated as they emerge from protocol research.
(S-25)

. . the California protocol for the physical examination of sexually
abused children should be considered a model, as it also specifies facility
standards, forensic tests, and laboratory tests for the presence of sexually
transmitted diseases (and contact testing, when positive). (S-26)

. . the assessment process should explore the possibility that other
members of the victim's household have experienced childhood sexual
abuse or other forms of family violence. (S-27)

. . the assessment process - with the aid of standardized forms, one-
way mirrors, a minimum number of designated examiners, video- and/
or audiotaped interviews, photographs, and careful scheduling - should
keep to a minimum the need to re-interview, re-examine, and re-trau-
matize the child and the family. (S-28)

. . . consultations and second opinions should be rendered, whenever
possible, on the basis of a review of documents and a discussion with

60


the original interviewing team, rather than on a re-examination and/or
a return interview. (S-29)

. . specialized, comprehensive intervention should help the entire fam-
ily and/or substitute family understand what happened, acknowledge
their feelings, explore their fears, and separate past from present coping
mechanisms. (S-30)

. . . the goals of intervention should be to reduce symptoms, to enhance
the individual's and family's ability to adapt positively to the situation,
and to promote the growth and development of each child. (S-31)

. . . the treatment program for the victim of child sexual abuse should
begin immediately and continue according to a plan which is rewritten
as the child's needs evolve. (S-32)

. regional resource centers should be developed to offer treatment
consultation for difficult cases, especially in medically underserved areas,
and to guide new self-help groups, to gather data, to coordinate regional,
legal and social service providers, to train workers, and to provide other
kinds of educational assistance. (S-33)

CHILD SEXUAL ABUSE: PREVENTION

           CHAIR: Robert ten Bensel, MD, MPH
ADVISORY COMMITTEE MEMBER: Saleem A. Shah, PhD
          RECORDER: Bruce D. Poulter, RN
       PARTICIPANTS: Rosemary Barber-Madden, EdD
               J. Jarrett Clinton, MD
              Jane Delgado, PhD
               David Finkelhor, PhD
                    Helen Howerton
              Dodie Livingston
               Terry W. McAdam
                Ramona T. Mercer, RN, PhD, FAAN
              Cdr. Richard Moore, Jr., MD, MPH,
                    USCG

Suellen Muldoon
Karin Murray
Robin Rushton
James C. Shine

61


Members of this work group introduced their recommendations wirh
the following set of background assumptions:
o Abuse is everyone's business. The health, mental heulth, and economic
costs associated with abuse affect all Americans now and in the future.
  Prevention is directed both
i&h risk for sexual abuse.  at the p&/jl- and at the tqqeted gr(~tP.' (If

o Primary prevention of child sexual abuse concerns stopping abusive
behavior before it occurs; .reron&ry prevention concerns early identinca-
tion and treatment of the victim of abuse.
. Culturally sensitive approaches must be integrJ to all recommendations.
o American society must realistically confront the phenomenon of child
sexual abuse.

o Our first priority must be to protect the child.

In the area of Education we recommend that _ . .

. . . an aggressive public education campaign, emphasizing sexual abuse
as a harmful and criminal act, should be carried out with the objective
of stopping the sexual abuse of children. (E- 17)

. . . the public should be given the facts about child sexual abuse and
the options available for prevention and treatment. (E- 18)

. . . core curricula for undergraduate, graduate, and continuing edu-
cation programs for health and human service professionals should in-
corporate authoritative, appropriate material on child sexual abuse,
including material on prevention and techniques for intervention.
(E- 19)

. . . educators, parents, and public health officials should provide all
children, from elementary school on, with well-evaluated materials on
the prevention of child sexual abuse, including (at a minimum) material
on sexual abuse, appropriate and inappropriate touching, the right to
say no to inappropriate touching, appropriate and accurate sexual ter-
minology, and the importance of telling someone when sexual abuse
occurs. (E-20)

. . . educators, parents, and public health officials should design, test,
and put into their elementary and secondary schools programs that teach
effective parenting skills and child development, in order to foster a new
generation of parents better able to prevent - and less likely to per-
petuate - the sexual abuse of children. (E-2 1)

In the area of Research we recommend that . . .

62


. . . a national search should be carried out to identify, evaluate, high-
light, and disseminate information about effective primary prevention
programs for child sexual abuse. (R-20)

. . . the research agenda should be expanded along the following lines:
. gaining more specific knowledge of the incidence and prevalence of
child sexual abuse among specific segments of the population;
o conducting prospective longitudinal studies in order to document and
better understand the short- and long-term effects of disclosed and
undisclosed child sexual abuse;

. identifying high-risk children and families and delivering preventive
educational programs to them;

. evaluating a broad range of preventive educational programs;
. identifying normal sexual development and behavior in order to more
accurately identify deviant development and behavior;
. identifying the characteristics of men who are serious, repetitive per-
petrators of child sexual abuse;

o examining the role of parenting behaviors and the degree of involve-
ment of fathers in order to provide insight and to reduce their risk of
being sexual abusers of children;

o understanding the potential for further harm to a child as a result of
the disclosure of having been sexually abused and of the child's sub-
sequent involvement in the criminal justice system. (R-21)

In the area of ServrrCrr we recommend that . . .

. . key community, government, public health, and media and ad-
vertising professionals should work together to establish policies and to
encourage public and private initiatives for setting limits on the sexu-
alization of children in the media and advertising. (S-34)

. . . better coordination should be accomplished among federal, state,
and local programs, policies, and activities in law enforcement, prose-
cution, defense, social service, criminal and juvenile justice, and public
health in order to improve the identification and prevention of child
sexual abuse. (S-35)

. . . programs should be strengthened and expanded serving runaway
and homeless youth, since they are at high risk for sexual exploitation.

. . public/private partnerships and community-level cooperation ("net-
working") among family and youth services should be increased. (S-37)

. . federal, state, local, and private financial resources should be in-

63


creased to support programs that might effectively reduce the incidence
of child sexual abuse. (S-38)

ELDER ABUSE: EVALUATION ANDTREATMENT OF
       VICTIMS AND PREVENTION

          CHAIK: Jordan L. Kosberg, PhD
ADVISORY COMMITTEE MEMBER: Faye G. Abdellah, RN, EdD, ScD
           RECORDER: Frieda Outlaw
       PARTICIPANTS: Amy C. Barkin
              Danny Chin, MD
              Barry D. Lebowitz, PhD
                   Lee Pearson

Linda R. Phillips, RN, PhD
Karl Pillemer, PhD
Louis Rowitz, PhD
Jan Sinnott, PhD
Suzanne K. Steinmetz, PhD
Harry R. Tanner, MSW
Richardson White, Jr.

Members of the work group on elder abuse said the following assumptions
are basic to their recommendations:

. Competent older persons have the right to self-determination.
. No group is immune to elder abuse; the problem cuts across all social
classes and all racial, ethnic, and religious groups.

. Most older people live independently, while others live happily and
safely in the care of or in the homes of others; many American families
are heroic in the care they provide elderly relatives.
. Elder abuse is, in many instances, a result of the ageism prevalent in
our society.
. Elder abuse is part of the larger social problem of violence in contem-
porary American life.

In the area of Education we recommend that . . .

 health care providers, social service agencies, and criminal justice
professionals should receive education and/or training in the detection,
assessment, and treatment of elder abuse. (E-22)

64


. . educational programs should be developed to increase public un-
derstanding of elder abuse. (E-23)

. . . community educational and outreach programs should be developed
to help older people protect and take better care of themselves and to
make use of community resources. (E-24)

. . educational programs should be developed to illustrate the potential
for family violence throughout the life cycle and for the prevention of
such violence. (E-25)

In the area of Research we recommend that . .

. . national studies should be carried out on the incidence, prevalence,
dynamics, and outcomes of elder abuse. (R-22)

. . . studies should be conducted to detetmine the effectiveness of pro-
grams to prevent, detect, treat, and control elder abuse. (R-23)

. . items regarding elder abuse should be added to existing public
health surveys, such as the National Health Interview Survey and the
National Health and Nutrition Examination Survey. (R-24)

. . there be a national elder abuse clearinghouse for coordinating re-
search, training, and program development in the public and private
sectors. (R-25)

In the area of Services we recommend that . . .

. . services to elder abuse victims should include legal assistance, victim
advocacy, emergency and long-term housing, and other services that
help ensure the rights of older people to be independent and live free
from abuse. (S-38)

. . . additional services, such as respite care and adult day-care, should
be made available to help families care for members who are elderly and
vulnerable. (S-39)

. . . the criminal justice system should be better equipped to respond,
in cooperation with other agencies, to the problem of elder abuse. (S-
40)

. . such community coordinating mechanisms as case identification,
case management, crisis intervention, and communication linkages should
be developed and expanded to address the problem of elder abuse.
(S-4 1)

65


RAPE AND SEXUAL ASSAULT: EVALUATION AND TREATMENT

           CHAIR: Lee Ann Hoff, RN, PhD
ADVISORY COMMITTEE MEMBER: Ann W. Burgess, RN, DNSc
           RECORDER: Priscilla Kiehnle Warner
       PARTICIPANTS: Margaret Long Arnold
              Constance Avery-Clark, PhD
                Martha R. Burt, PhD
              Jane R. Chapman
              Fern Y. Ferguson, MSW
              Paul J. Fink, MD
                Shervert Frazier, MD
                 Norman Landsem
                  David A. Rust

Theoharis K. Seghorn, PhD
Maj. Henry F. Vader, USAF

Members of this work group introduced their recommendations by listing
these background issues:

. The general public, families of victims, and providers of human services
will only further victimize rape victims if they continue acting on the
basis of commonly held but mistaken myths and biases concerning rape,
or bringing insufficient knowledge and skill to the task of caring for
rape victims, or failing to accept a more responsible role in the evaluation
and treatment of victims. Rather, the community and its service pro-
viders must respond on the basis of the facts of rape and sexual assault.
. Rape is a crime of violence. It is not primarily a sexual act, whether
it occurs between strangers, acquaintances, or intimates. However, a
rape victim may have difficulty later experiencing normal sexual and
other interpersonal relations.
. Rape is rarely the act of a psychotic person. Rape is a criminal expres-
sion of power and domination inflicted primarily by men upon women,
although some victims are also men.
. Sexual violence is behavior learned from various sources, such as the
mass media, pornography, childbearing experiences, and family violence.
. Sex role stereotyping supports the unequal power relationships between
women and men. Traditional male socialization limits men's ability to
express tenderness and encourages their use of violence to resolve conflicts
rather than the use of communication and negotiation.

66


. Women have the right to say no and to have their refusal respected.
. Violence must be eliminated as a means of resolving conflict.

In the area of Education we recommend that . . .

. . . a nationwide public education campaign should be carried out giving
the facts about violence, sexual assault, and rape, including information
describing the type and extent of service a victim should expect to receive.
(E-26)

. . . professionals involved across a wide spectrum of health, human
service, and criminal justice activities - persons most likely to have
contact with rape victims - should be given information concerning
the evaluation and treatment of rape victims in basic professional prep-
aration and continuing education programs. (E-27)

. mental health professionals should take the lead in assuring the
relevance of their own education concerning sexual violence before of-
feting consultation services to police, educators, and others. (E-28)

. . . the planning for public education programs to correct the myths
and biases concerning rape ought to be carried out with an understanding
that the information will also be reaching and influencing health and
human service professionals as well. (E-29)

In the area of Research we recommend that . .

. . there be training programs specifically to prepare professionals to
conduct research in the area of rape and sexual assault. (R-26)

. . . the following research areas ought to be pursued:
. the epidemiology of rape;
. the social environment of rape and sexual assault;
. the types and effects of various intervention strategies;
. the longitudinal pattern of recovery by victims and significant others
from sexual assault, including thoughts, feelings, behavior, and general
health status;

. the behavior of sexual assailants, factors associated with assaultive
behavior, and the effectiveness of deterrents upon potential assailants;
. strategies and programs to change basic attitudes about rape;
. analyses of social and health costs and benefits from early intervention
and treatment following rape, compared with no action at all. (R-27)

In the area of Serz,ices we recommend that . . .

. . . the groups that accredit, certify, and license agencies and individuals
who provide emergency/crisis, mental health, criminal justice, and other

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human services should incorporate standards for the evaluation and treat-
ment of sexual assault victims. (S-42)

. . . clear guidelines and protocols, such as exist in many rape crisis
centers and hospital-based programs, should be sensitive to the experi-
ences and needs of rape victims of both sexes and be developed by every
community health facility. (S-43)

. . . institutions should provide a caring ombudsperson/expediter to
assist each victim through the evaluation and treatment process. (S-44)

. . . programs serving rape victims should conform to national standards
of various accrediting bodies in order to insure that they provide all the
recommended elements of coordinated, effective victim services. (S-45)

. . . technical assistance - such as program design, clinical protocols,
training curricula, and research results - should be readily available
from a central clearinghouse (e.g., SHARE) to communities that want
to develop their own service programs for victims of rape and sexual
assault. (S-46)

. there be adequate public and private funding for programs serving
victims of rape and sexual assault. (S-47)

RAPE AND SEXUAL ASSAULT: PREVENTION

         CHAIR: Eddie Bernice Johnson, RN, MPH
ADVISORY COMMITTEE MEMBER: Margaret T. Gordon, PhD
         RECORDER: Barbara Parker, RN, MS
      PARTICIPANTS: Harvey V. Fineberg, MD, PhD
             Henry W. Foster, Jt., MD
             Philip A. Harding
              Ann Maney, PhD
                  William Oltman

Murray A. Straus, PhD
Marvin E. Wolfgang, PhD
Laura x

Members of this work group introduced their recommendations with
the following preamble:

o As part of their basic right to personal safety, all people - male and

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female alike - have the right to control access to their bodies. Rape
and sexual assault violate this basic right.
. Rape and sexual assault are brutal crimes with potentially life-shat-
tering consequences for victims and with disruptive effects for society.
The following recommendations are offered, therefore, to help society
reduce and ultimately eliminate these crimes.
. "Sexual assault" is here defined as "nonconsensual sexual behavior,
including stranger, acquaintance, and spousal assaults against either male
or female victims. "

. We recognize that substantial financial outlays will be required to carry
out these recommendations. In view of the significance of rape and sexual
assault as devastating public health problems, we urge that adequate
funding for these recommendations be made available from both public
and private sources.

In the area of Education we recommend that . . .

. . . increased public education should be carried out to bring about
equality between women and men, since it has been shown that the rate
of rape is low where the status of women is high. (E-30)

. public awareness should be heightened regarding 1) the legal,
statistical, and human service definitions of rape and sexual assault; 2)
the myths and facts surrounding each; 3) the impact of these crimes on
victims and families; 4) the need for crisis services; and 5) the harm that
comes to individuals and society from our nation's high tolerance of
violence and aggressive behavior. (E-3 1)

. . specific educational programs need to be designed for potential
victims (especially high-risk populations), potential assailants (especially
pre-adolescents and adolescents), and such professional persons as those
in health care, law, religion, education, and human services. (E-32)

In the area of Research we recommend that . . .

. studies be carried out to determine which educational campaigns
are most effective for preventing rape and sexual assault. (R-28)

. . a clearinghouse on rape and sexual assault should be established to
gather baseline data, provide technical assistance, and circulate infor-
mation drawn from research, education, community action, and health
and human services. (R-29)

. . . the human service, statistical, and legal communities and the general
public need to re-examine their definitions of rape and sexual assault.
(R-30)

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. . the way sexual aggression is portrayed in the mass media ought to
be studied and evaluated for its effects upon the public health. (R-3 1)

. . . researchers should give additional attention to the following areas:
. victim and bystander strategies thar do or do not stop rapes in progress;
. how the mass media do or do not encourage sexual assault;
o treatments that do or do not change assailant behavior;
. behavioral antecedents of assaultive behavior;
. the role of incarceration in prevention;
. situations and conditions in which rape occurs;
o and the constraining effects of a person's fear of rape. (R-32)

. I , qualified researchers should be called together to set an agenda of
the research that needs to be done in rape and sexual assault. (R-33)

In the area of Services we recommend that . . _

. . . all sexual offenders, especially adolescents and pre-adolescents show-
ing sexually deviant behavior, should be identified, evaluated, and treated
as early in life as possible. (S-48)

. . the criminal justice system should clearly recognize sexual assault
as a serious violent crime; that sanctions, including incarceration, should
be imposed upon assailants commensurate with the devastating impact
of the crime upon their victims; and that treatment to prevent future
criminal behavior be part of sentencing wherever possible. (S-49)

. . . all remaining states and territories should remove the husband's
exemption from prosecution for the rape of a wife, as is now the case in
28 states. (S-50)

. designers of cities, buildings, and transportation systems should
pay more attention to the problem of reducing the risk of sexual assault
in their projects. (S-5 1)

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SPOUSE ABUSE: EVALUATION ANDTREATMENT

            CHAIR: Luella Klein, MD
ADVISORYCOMMIITEEMEMBER: Alan WurtzeI, PhD
            RECORDER: Sara Torres
        PARTICIPANTS: Carole Anderson, RN, PhD
               Mary Pat Brygger
              Jacquelyn C. Campbell, RN
                Elaine Hilberman Carmen, MD
              Phyllis Old Dog Cross, RN, MS
               Lt. Joseph DiPaolo, MSC, USN
              Juanita K. Hunter, RN, EdD
                Arnold S. Kahn, PhD
                  William Modzeleski
                Lenore Walker, PhD
               R. Dale Walker, MD
                  Barbara Shaw

Members of this work group on spouse abuse introduced their recom-
mendations with the following preamble:
. The phenomenon of "spouse abuse" includes physical, sexual, and
psychological abuse and is found in all social, economic, ethnic, and
racial groups.
. Spouse abuse is a crime perpetrated primarily against women, often
causing them serious injury and premature death and affecting the psy-
chological development of their children and of other family members.
. Spouse abuse is not a private matter; it has ramifications beyond the
immediate family.
. Spouse abuse is rooted in a sexist social structure that produces profound
inequities in roles and relationships and in the way resources and power
are shared by men and women in families.
. All public policies that encourage or support spouse abuse and other
forms of interpersonal violence are wrong; they should be reviewed and
changed.
. Interventions that "blame the victim" and do not hold the abuser
accountable are ineffective and inappropriate.

In the area of Education we recommend that . . .

. . . information on interpersonal violence, including spouse abuse, should

71


be a part of the basic education and training curriculum for all health
professionals (physicians, psychologists, nurses, social workers, counse-
lors, health educators, etc.), as well as for teachers, lawyers, police, and
others who serve the public. (E-33)

. . . information on interpersonal violence, including spouse abuse, should
be part of post-graduate and continuing education for health professionals
and faculty. (E-34)

. . . certification, licensing, credentialing, and board examinations should
include questions on interpersonal violence and spouse abuse so that
health professionals and faculty have at least minimum knowledge of
these phenomena. (E-35)

. . the identification of victims and abusers and some knowledge of
appropriate interventions and intervention strategies should be part of
standards of practice and recommended standards of care for such various
health disciplines as nursing, psychology, social work, health education,
and medicine (pediatrics, psychiatry, family practice, obstetrics-gyne-
cology, orthopedic surgery, and emergency medicine). (E-36)

. . . the Surgeon General should develop a public information and ed-
ucation campaign identifying spouse abuse as a major public health
problem. (E-37)

. . . realistic standards need to be developed to help reduce the level of
violence in all mass media, since - despite occasional and excellent
examples of self-regulation - violence is still over-represented in the
media. (E-38)

In the area of Reseat-c;CI we recommend that . . .

. . . federal agencies should identify and coordinate their spouse abuse
research and make sure that the results are widely disseminated. (R-34)

. . . the resources available for research on the prevention, causality,
treatment, and intervention of spouse abuse and family violence ought
to be proportionate to the high priority of this problem, when compared
with other public health problems. (R-35)

. . . a number of research opportunities in violence ought to be pursued,
such as . . .

. longitudinal studies of victim/survivors of spouse abuse;
o research among different vulnerable populations at high-risk for spouse
abuse, such as racial and ethnic minorities and persons with low so-
cioeconomic status;

. evaluation of models of intervention and prevention in spouse abuse
and of models of the processes by which abusers stop abusing;

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o the kinds of state and local policies that effectively reduce violence
and protect victims;

. risk factors that may predict homicide in violent relationships;
. the relationship between an abuser's intake of alcohol and drugs and
the frequency, severity, and lethality of the abuse of his spouse;
. how personal and environmental factors interact and escalate spouse
abuse;

. the relationship between violence in mass media and spouse abuse;
. the way psychological assessment tools may be adapted to measure the
psychological impact and other post-traumatic stress disorders upon
the victims of spouse abuse;

. relationships between stress-related disorders and spouse abuse;
. the long-term effects upon health and social service providers who
work in the area of spouse abuse;
. the characteristics and coping skills of women who have left violent
relationships;

. characteristics of batterers in order to determine causation of male
aggression against women;
. the long-term impact on children who witness spouse (parent) abuse.
(R-36)

In the area of Services we recommend that , . .

. . . the first priority for intervention in spouse abuse must be to provide
shelters, safe homes, and other protective environments for victims and
their children. (S-52)

. . every community should have available a full range of fully funded
and fully coordinated health, mental health, legal, and social services
for victims, abusers, and their children. (S-53)

 spouse abuse services should include the kind of innovative and
creative treatments that address the specific economic, social, and cultural
needs of vulnerable populations. (S-54)

. intervention strategies must hold abusers accountable for their vi-
olent behavior. (S-5 5)

. . . protocols for spouse abuse identification and intervention should be
developed and used by health care professionals in all settings, such as
emergency rooms, trauma centers, primary care sites, mental health
centers, psychiatric hospitals, and physicians' offices. (S-56)

. . all existing and proposed typologies should be examined to eliminate
victim-blaming. (Consistent with this recommendation, we oppose the
proposed new DSM III-R psychiatric diagnosis 301.89, Masochistic Per-

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sonality Disorder, which may be applied to victims of spouse abuse.
This diagnosis is victim-blaming, pejorative, and sexist. It would be
harmful and counterproductive to identification, intervention, and pte-
vention strategies.) (S-57)

. . the Surgeon General should vigorously pursue adequate federal
funding for spouse abuse programs, particularly the funding to carry out
the Family Violence Prevention and Services Act. (S-58)

. questions concerning possible spouse abuse should be included on
prenatal history forms and be routinely asked during medical, nursing,
and social work assessments of pregnant women. A physically ot sexually
abused pregnant woman should be identified as having a high-risk preg-
nancy and be eligible for high-risk prenatal care. (S-59)

SPOUSE ABUSE: PREVENTION

CO-CHAIRS: Anne H. Flitcraft, MD
      Evan Stark, PhD

ADVISORY COMMIITEE MEMBER: Delores L. Parron, PhD
        RECORDER: Sgt. Jean D. Albright, USAF
       PARTICIPANTS: Maj. Linda Boone, USMC
             Gary L. Bowen, PhD
              John A. Calhoun
                 Karla M. DiGirolamo
             Richard J. Gelles, PhD
              Jean Hilsman

Janice Humphreys, RN, MS
Laura Smith McKenna, RN, DN
Toby Myers, EdD
K. Daniel O'Leary, PhD
Lt. Rosemary Pezzuto, USCG

The members of this work group agreed that the following issues and
problems need to be addressed by the recommendations:
. The acceptance of violence as a means of responding to and resolving
interpersonal and marital problems is widespread in our culture.
  . Women have historically been the most likely target of family violence;

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hence, health care professionals must take the lead in guaranteeing the
physical integrity of women.
. Spouse abuse and woman battering each has an incremental/develop-
mental sequence, which, if unchecked, will result in increased physical,
psychological, and social morbidity of the victims.
. The link between child abuse and spouse abuse is well-documented;
therefore, efforts to prevent spouse abuse and woman battering are also
major factors in the prevention of child abuse.
. The major objectives of a prevention program in spouse abuse and
woman battering ate to identify the problem, to protect the victim, to
stop the violence, to expand the options, and to empower women.

In the area of Education we recommend that . . .

. . . programs to prevent domestic violence should be developed by
federal, state, and local educational agencies and carried out in insti-
tutions at all levels. These prevention programs should focus on the
following:
. the causes, dimensions, consequences of, and responsibility for inter-

personal violence;

. the relationships between violence and power, control, gender ster-

eotypes, and sex roles; and

. the nonviolent resolution of interpersonal conflict. (E-39)

. . . national leaders in health care, politics, business, labor, religion,
culture, and the professions should declare their opposition to spouse
abuse and woman battering and should develop and distribute appro-
priate educational materials to their constituents. (E-40)

. . . the Surgeon General should initiate a major media campaign de-
signed to prevent spouse abuse and woman battering. The campaign
should highlight the following points:
. spouse abuse and woman battering are against the law;
. the physical integrity of all family members is a basic health right;
. spouse abuse and woman battering have serious health consequences;
. battering is not limited to any group, gender, racial minority, geo-

graphic area, or social class;

. normative male behavior is itself a potential health hazard;
. shared decision-making and nonviolent conflict resolution are prefer-

able to male dominance and the use of force; and
. services are available for abusive adults and their victims. (E-41)

. . . curriculum materials on spouse abuse and woman battering should
be introduced into the education, training, and continuing education of

75