Surgeon

General's

Leesburg, Virginia
October 27-29, .I985


Surgeon General's
Workshop on
Violence
and Public Health

Report

Sponsors

U.S. Department of Health and Human
Services: the Alcohol, Drug Abuse, and
Mental Health Administration, Centers for
Disease Control, Health Resources and Ser-
vices Administration, and National Institutes
of Health of the U.S. Public Health Service
and the Administration on Children, Youth,
and Families and the Administration on De-
velopmental Disabilities of the Office of Hu-
man Development Services

U.S. Department of Justice: the Office of
Juvenile Justice and Delinquency Prevention

Leesburg, Virginia
October 27-29, 1985


       U.S. Public Hwlth Service
U.S. Dqmrtmmt of Health nnd Human Swviccs (DHHS)

DHHS Publication No. HRS-D-MC  X6- I


Contents

Plenary Session I

C. Everett Koop, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  3
Surgeon General, USPHS

Plenary Sesssion II

Marvin E. Wolfgang, PhD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9
Director, Sellin Center for Studies in Criminology and
Criminal Law, University of Pennsylvania

William H. Foege, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Assistant Surgeon General and Special Assistant for
Policy Development, Centers for Disease Control

Plenary Session III

Karil S. Klingbeil, MSW, ACSW . . . . . . . . . ._... . . . . . . . . . . . . . . . . . . . . . . 25
Assistant Administrator and Director of Social Work,
Harborview Medical Center, and Assistant Professor,
School of Social Work, University of Washington

Deborah Prothrow-Stith, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35
Assistant Professor of Medicine, Boston University
School of Medicine, and Attending Physician,
Boston Youth Program

Anthony V. Bouza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . _. . . . . . . . . _ . . . . _ 44
Chief of Police, Minneapolis, Minnesota

Plenary Session IV

Recommendations of the Work Groups:

Assault and Homicide: Evaluation and Treatment.. . . . . . . . . . . . _. . . . . .49
  Assault and Homicide: Prevention.. _ . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Child Abuse: Evaluation and Treatment.. . . . . . . . . . . . _. . . . . . . . . . . . . . . .54
  Child Abuse: Prevention _ __ _. . . . . . . . . . . . . . . . _ _. . _ _. . . _. . . . _. . . . . .56


Child Sexual Abuse: Evaluation and Treatment ...........
  Child Sexual Abuse: Prevention. ......................
Elder Abuse: Evaluation and Treatment of Victims
  and Prevention .........................................
Rape and Sexual Assault: Evaluation and Treatment ......
  Rape and Sexual Assault: Prevention .................
Spouse Abuse: Evaluation and Treatment ..................
  Spouse Abuse: Prevention .............................

......... .58

......... .61

......... .64

......... .66

......... .68

......... .71

......... .74

Plenary Session V

C. Everett Koop, MD _. . . . . . . . . . . . . . . . ._. _. . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Surgeon General, USPHS

The "Delphi" Survey ......................................... . . .._...... 84
List of Participants ............................................ _ . . . . _ . . . . .92


Plenary Session I

Welcome and "Charge" to the Participants

Prescntcd by C. Everett Koop, MD
Surgeon General of the U.S. Public Health Service
Sunday evening, October 27, 1985

Let me personally thank you all for accepting my invitation and coming
to this workshop. Before we end our work on Tuesday, I hope I will have
been able to thank each of you in person.
I will be here throughout the workshop, and I hope to visit each work
group once to catch at least the sense of your deliberations.
I have also assigned each member of my "Ad Hoc Planning and Advisory
Committee" to a specific work group. I have asked each one to be helpful
to the chair when needed and in other ways carry my personal interest to

- and from - those important work sessions.
I will also rely on them to help me frame my response to the recom-
mendations that arc to be presented in the fourth plenary session on Tuesday
afternoon.

Because they've been so important to the planning of this workshop over
the past 13 months - and because they continue to be important to the
way we proceed - I'd like to take a moment to introduce them to you in

3


alphabetical order: Ann Burgess, Ted Cron, Margo Gordon, Dave Heppel,
Tom Lalley, Bob McGovern, Nikki Millor, David Nee, Eli Newberger,
Delorcs Parron, Mark Rosenberg, Saleem Shah, and Alan Wurtzel.

If you're still wondering by what magic your name came to my attention,
please be assured that it wasn't through magic at all but rather through
the diligence of this committee reaching out into the larger community.
They spent almost 6ve months searching out the best possible people to
come together to share what they know and what they see as the things
still to be done.

Let me hasten to add that many excellent people arc not here and their
absence may be noted. First, it is possible that WC did invite them, but
they either had to decline or, after accepting, found they could not make
it after all. Others did not receive an invitation for the time-worn but
unsatisfactory reason of space: We asked Xerox for just so many spaces . . .
150 of them . . . a number we felt was the maximum for a workshop in
which we hope everyone will contribute.

But I would be very disappointed if this were both the first and the last
workshop on this subject. I am hoping that our experience here will be
repeated in the coming months in every region of our country and that,
as a result, many of the people who arc missing from this workshop will
have a chance to contribute in the future through those follow-up events.
1 understand that such may well be possible in the southwest, thanks
to the people here from Texas. And later this week, my staff will be talking
with some people from the midwest about a follow-up meeting there.
But the prize for immediate follow-up ought to go to the nurses who
arc here. A contingent of the "Leesburg Nurses" will form a panel and
present the recommendations of this workshop on Friday evening, at the
opening session of the "First National Nursing Conference on Violence
Against Women," being held N ovember 1 through 3 at the University of
Massachusetts at Amherst.
Congratulations . . . good for you.
For most of you, I'm sure this will not be your only conference on
violence this year. Some of you will have attended several before the year
has ended.

But I hope the Leesburg Workshop will be different in one major respect:
Our focus will be squarely on how the health professions might provide
better care for victims of violence and also how they might contribute to
the prevention of violence.

It is clear that the medicine, nursing, psychology, and social service
professions have been slow in developing a response to violence that is

4


integral to their daily professional life. As a result, WC arc not sure if the
estimated 4 million victims of violence this year will receive the very best
care possible.

Nor can we be sure that enough will be done to prevent violence from
claiming 4 million or more victims again next year.
I think we all share these nagging suspicions. Fortunately, we also seem
to share the same notions about what can be done about them and how
we can do it.

That is one of the interesting outcomes of the "Delphi" survey that so
many of you took part in over the summer. According to the final report,
we generally agree on many ideas that lead directly to action.

Multidisciplinary Approach

One such idea is that the best approach the health professions can make
to interpersonal violence is a multidisciplinary approach.
We know we have not been as successful as we would like to be in the
care and treatment of victims of violence because of the way our health
professionals continue to indulge in compartmentalization . . . the vertical
separation of one life-saving service or discipline from all others.
It's a frustrating habit we've developed, but one which we agree should
be ended as soon as possible and as effectively as possible.
For just that reason, we have a range of disciplines, skills, and experience
represented at this workshop. Through our own multidisciplinary delib-
erations, we might produce recommendations for the profession of medi-
cine, for example, that not only reflect actual and potential medical practice,
but also reflect the contributions of social services, nursing, and law en-
forcement, as appropriate.

Ideally, the multidisciplinary approach we're taking here in Leesburg
ought to be replicated in every community in the Nation. I say "ought
to," but I know it can't be accomplished in most of the country. Therefore,
reality dictates that we produce here the kinds of recommendations that
reflect the thinking of many disciplines, yet recommendations that can be

- themselves - the stimuli of change and progress everywhere.
Here, again, through the "Delphi" technique, we seem to have reached
general agreement on another idea, and that is the fact that we've had
ample time to develop our theories and concepts. What we 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

5


service anywhere in the country can absorb them, understand them, and
put them into practice.

. 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. To say we're in favor of a
multidisciplinary approach is obviously not enough. We need to focus
in on those current multidisciplinary programs that seem to work . . .
to isolate and describe their elements . . _ and then indicate how they
can be replicated in any community or institution.

. We also need to be just as pragmatic in the area of education and
information. How can we get certain life-protective messages across to
young people? . . . to our elderly? . _ . and to our colleagues in the
health professions? And what role could our public schools, our profes-
sional schools, and our professional associations play in this educational
effort? And what ought to be the role of the media . . . television, radio,
newspapers, magazines?

. While we might feel we have learned enough from research and ex-
perience 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. I hope
these will be discussed here and later put forward among your recom-
mendat ions, also.

From these two days of hard work should come a document that can be
read in two ways. One way would be to read the recommendations, one
by one, for the evaluation and treatment of victims and for the prevention
of violence. These recommendations could apply to the various professions,
to local and state governments, to voluntary organizations, and to academia
according to a cross-grid of the different kinds of interpersonal violence:
child abuse, spouse abuse, rape, and so on.

The second way to read the document would be not as specifics but as
an overall strategic design.

One of the great deficits of our health delivery system generally has been
its stubborn resistance to the development of any overall strategy of care.
I will not concede that there's a good reason for this because there isn't.
But there is a bad reason. And that reason is our own unwillingness to

6


really try. We have become so used to a health system that grows and
changes incremently that we think that's the way things ought to be.
But that's not so.

And so I would hope that here at Leesburg we would not fall into the
same particularistic trap that we bemoan as existing everywhere else.
Let's not do that. Let us instead arrive at a set of recommendations that
make sense by themselves . . . but make even more sense when they are
perceived together, sewn throughout a seamless fabric of lifesaving, dignity-
preserving, quality health care.

I want that to happen here at Leesburg. I believe it's an assignment that
is worthy of the knowledge, experience, and reputations assembled in this
room.
And now a closing word.
It had been our intention to take the recommendations of the Leesburg
Workshop back into Washington, D.C., and hold a press conference on
Wednesday morning to make our findings public. However, I believe we've
been given an opportunity to start the public education effort in a very
important way.

Special Senate Hearing

I'm pleased to report to you that at 11:OO a.m. on Wednesday morning,
we will be appearing before the Senate Subcommittee on Children, Families,
Drugs, and Alcoholism to report on what will have transpired at this
workshop. We are going at the invitation of the Chair of that Subcom-
mittee, Senator Paula Hawkins of Florida, who has been a strong voice in
the Congress on behalf of human life and family values.

I say "we" have been invited because Senator Hawkins has graciously
asked six of our 11 work-group chairpersons to appear with me. They are
Douglas Sargent, Anne Flitcraft, Lee Ann Hoff, John Wailer, Jean Good-
win, and Jordan Kosberg. They will speak not for themselves, obviously,
but on behalf of all of us. I deem it a great privilege to travel in such
company. In fact, I'm delighted to go to Capitol Hill with any company
at all. But especially with these six.

It's getting late and I know many of you are eager to exchange greetings
with colleagues, visit the special presentations arranged in the meeting
rooms as part of the "information exchange" this evening, and prepare for
tomorrow's work.

So I will close with a little quotation from one of my favorite American
writers, Henry David Thoreau. He seems appropriate for this setting.

7


In his marvelous book, Walden, Thoreau wrote, "It is characteristic of
wisdom not to do desperate things."
So let us turn to our work with patience and wisdom, and not out of
desperation. Instead, let us pledge that despair is over . _ . for all our
people.
And let's start here.
Thank you.


Plenary Session II

Interpersonal Violence and Public Health
Care: New Directions, New Challenges

Presented by Marvin E. Wolfgang, PhD
Director, Sellin Center for Studies in Criminology and
Criminal Law, University of Pennsylvania*
Monday morning, October 28, 1985

The Founding Fathers of our nation had the wisdom and foresight to
remind us in the Preamble of the Constitution of the great challenges and
goals that lay ahead. Six national purposes, charges, and mandates for the
future were boldly inscribed there as part of the national consciousness. As
a'nation we have sought in common cause to fulfill those purposes. To
nurture and preserve that more perfect union after which our forebears
sought, the nation has had to remain vigilant to protect its spirit and body
from threats from both without and within. One of the most damaging
and pernicious internal threats that has taken on major proportions over
the course of our history is violence in its many forms and gravities.

Deep and longstanding concern about our nation's violent past and
present produced the presidential appointment of the National Commission

* With Neil Alan Weiner, Research Associate, Sellin Center for Studies
in Criminology and Criminal Law, University of Pennsylvania.

9


on the Causes and Prevention of Violence in 1968. For the first time at
the national level this dark side of our heritage was illuminated system-
atically and in depth. The summary of the 13-volume report prepared by
the Violence Commission chronicled with precision this enduring and per-
vasive national malady (U.S. Violence Commission 1969). Among the
community of nations most similar to our own in culture and history, those
modern, stable democratic states of Western Europe, our nation was planted
at the summit in levels of lethal interpersonal criminal violence and col-
lective civil violence. More recent documentation confirms these observa-
tions and suggests that America is also an international leader in nonlethal
forms of assaultive conduct (Archer and Gartner 1984; Wolfgang and
Weiner 1985). Indeed, as the Violence Commission established, the 1960s
witnessed levels of violence which were substantially greater than those of
preceding decades and ranked among the most violent in our history.

Since the 1969 report of the Violence Commission, levels of violence in
our national community have increased dramatically, if we use official police
records of criminal violence; or they have remained fairly stable since 1973
but at much higher levels than those documented by police sources, if we
use reports of criminal victimizations (U.S. Department of Justice 1984;
Weiner and Wolfgang 1985). Our nation not only suffers losses of stature
and moral example because of its levels of violence, which exceed the
proportions of kindred nation states, but also finds itself at its zenith in
this ignobling respect.

Focus on "Tranquility"

The Violence Commission elected to carry out its charge by focusing on
the means "to establish justice and to insure domestic tranquility," the
first two national purposes penned in the Preamble to the Constitution.
Tensions between justice and public tranquility and order were guiding
concerns in the quest of the Violence Commission to understand and to
prevent violence. In that analytical and philosophical context, violent dis-
order was dissected with the cutting instrument of criminal law and the
system of criminal justice. Although various theories were used to reveal
the causes of violence, the primary inquiry was from the viewpoint of
violative and unlawful behavior.

The Founding Fathers seemed prescient in their deliberations and con-
stitutional framing. They inscribed another viewpoint and objective into
this nation's first legal document: namely, the promotion of the general
welfare. Now this workshop on violence is fueled by that original national
purpose. The disorders of violence are as much a challenge to the general

10


health and welfare of our nation as they are to its system of justice and
law. Our objective at this assembly is to wed to the insights and advance-
ments of law, order, and stability, those of public health and welfare.

Fused to "America the Beautiful" has been "America the Violent." Ours
is a land in which people inflict morbidities and exact premature mortalities
in enormous proportions and in many different ways. The nation has been,
and continues to be, fearful of these assaults and related victimizations
(Weiner and Wolfgang 1984).

The formal promotion of the public health initiative in response to
violence is dated with the presentation of the U.S. Surgeon General's
national health agenda, Healthy People: The Surgeon General's Report on Health
Promotion and Disease Prevention (U.S. Department of Health and Human
Services 1979), which identified 15 priority areas that, with properly tar-
geted preventive interventions, would improve appreciably the health of
the nation. This document was the wellspring from which soon flowed
quantified and feasible policies to reduce violence and other threats to the
national health and vitality (U.S. Department of Health and Human Ser-
vices 1980). Our current workshop on violence, a direct outgrowth of these
milestone precedents, can inaugurate a major and continuing enterprise by
health care professionals to prevent and to heal the many wounds inflicted
by violence on our nation's physical, emotional, and cultural corpus.

A Catastrophe and a Challenge

Many sources can be consulted to document the extent and character of
these lethal and nonlethal interpersonal exchanges. Some of these sources
are more reliable and nationally representative than others. However, one
need not search much beyond the pages of the background papers prepared
for this workshop to obtain a measured and riveting picture of the catas-
trophe and challenge which confronts the nation (U.S. Surgeon General
1985). Consider the most grave interpersonal exchanges. Homicide ranked
as the 1 lth leading cause of death of Americans in 1980. Approximately
24,000 Americans died by the hand of another in that year, resulting in
690,000 potential years of life lost. These deadly assaults comprised one-
seventh of all deaths by injury (Baker, O'Neill, and Karpf 1984). Most
grimly, for a young black male aged 15 to 24, homicide is now the most
likely cause of death. Indeed, over his lifetime, a black male is burdened
by one chance in 2 1, compared to one chance in 13 1 for a white male, of
dying in a lethal encounter (U.S. Department of Justice 1985). But the
proportions of lethal exchanges are dwarfed by the numbers of morbid

11


nonlethal incidents. More than 1.5 million aggravated assaults of Americans
age 12 or older were reported in 1980, representing a substantial number,
indeed, of instances in which a deadly drama might have unfolded and
been played out to a lethal conclusion.

These lethal and gravely assaultive episodes have their contexts of oc-
currence which shape the likelihood and character of the injurious interplay.
It is fitting that the patterns in interpersonal violence which form the
primary focus of this workshop are those imbedded in the family. The
national tranquility is deeply afflicted by these disturbances in the domestic
microcosm.

That intimate nuclear family unit which broke bread together at dusk
and which huddled close to hearth and home forms a rich part of the
national lore and folk imagery. But the American family has also had its
darker side which has rarely turned public. As we are finding increasingly,
the family united in common purpose and objective is frequently more a
myth than a reality. Domestic life is often rent from within, making enemies
of intimates. Domestic tranquility is, as we are becoming more aware,
threatened profoundly by its internal dissentions, disruptions, and injurious
and deadly conflicts.

Tallies vary, but convergent data point to between five and 20 percent
of the adult population as being enmeshed in some form of spousal abuse,
                              _-_.--,_" -. ,-.          `. .-._ ..^ ".
comprising approximately four million domestic partners. Nearly 50 per-
                                  -e-.-.-
cent of those husbands who batter their wives do sx brutal regularity,
three or more times a year. Other data, from the National Crime Survey,
indicate that nearly one-third of the nation's abused women are serially
victimized. Spousal abus    n fact, be the foremost cause of injury to
                    -        -_L_--.- -.~-.- __ _.
women.

Nor are the nation's children immune from assaults and batterings and
sexual attacks by their parents and other guardians and caretakers. A recent
national survey projected that nearly 1.5 million children and adolescents
are subjected to abusive physical violence each year (Gelles and Cornell
1985).

Many abused children are sexually violated, forcefully or through the
implicit threats of a parent or caretaker in a position of authority and power.
Scant information exists but some figures are enlightening and alarming.
In 1984, nearly 125,000 cases of sexually abused male and female children
were reported to authorities. Prevalence figures for women who were sex-
ually abused before age 16 run between 25 and 50 percent. Peak abuse
ages for male and female children fall between 9 and 12. Between one-
quarter and one-half of the abuse cases involve a family member or relative.

12


Little reliable information has been marshalled about the extent and
outcomes of domestic violence suffered by the elderly. What few studies
have been conducted are more exploratory than comprehensive. In view of
the patterns and proportions of other forms of familial violence, it is unlikely
that we will be heartened when these hidden figures are uncovered.
The domestic crucible is becoming increasingly recognized as having
profound effects, both immediate and long-term, on its members who
experience violence directly or indirectly. Physical pain and suffering and
                                                       -,-
related physical morbidities .are. ,the more. .obvious. distressing outcomes.
_c__ - ..----.---
Disturbances in emotional and social development and in irnp&r,-zg-
ni tive skills are ls~-w~~~e~~~~~~u~~-~~-~~~~~~~ ~io~e~~X'lG%e
--._ __-__ .___ .!- __   ,_~_. ,___ ..,..                 -- -_-..-I ._,_
                _..
consequences are now documented with greater regularity, as you are all
aware.

Long-Lasting Effects

Of equal concern is the effect that domestic violence, particularly against
our nation's children, can have on shaping similar behavioral forms beyond
the domestic circle. Perhaps most disquieting children who are battered,
                          II_..  --  r--- -.-- - .__ ~_..
or who witness physical
---- _.. -    assaults among other -family members, are more
likely to carry the force of these episodes into their nonfamilial interactions
__-- .._____. __.- . . r     ,~--   .~.                .-.-_^ ,,._-. ^
in the form of a heightened._chance
~=- i .__-_<..--.~-&.        of employindolence as a presumed
                                          - _.____._ -_- _ __.. .-.. _.- .- .._

legitimate interpersonal St-y, The legacy of the violent family is the
         .- __... -.- .-- -._-
enhanced risk of applying variations of this same violent behavior in contexts
beyond the family setting.

The proportions and gravity of family violence and its facilitation of
collateral forms of interpersonal violence argue persuasively for selecting
the family as the locus of a primary initiative to apply health care approaches
to the reduction and control of violence. The benefits and conquests of the
medical and public health models are well known with respect to controlling
and, in some cases, eradicating disease and the behavioral contributions to
poor hygiene and health. Descriptive and analytical epidemiological re-
search and practice have met great challenges of disease and injury on many
fronts: in identifying high-risk Populations, in tracing the mechanisms by
which theoretical risk is turned into actual malady, and in applying the
tripartite prevention strategy - primary, secondary, and tertiary inter-
ventions - based on epidemiological breakthroughs into preventive and
control regimens. Agents, environments, and hosts have each been proper
foci in meeting the challenge of disease control.

The instruments of the health care provider, the conceptual and meth-

13


odological perspectives employed in public health care, and the modalities
of assistance and intervention that are practiced rourinely in the health care
setting have a legitimate and firm place as part of our national armament
against interpersonal violence. Past medical and health care applications in
this area, primarily in application to crime in general and to violent crime
more specifically, have been restricted to a subordinate part of criminal
justice and social problem perspectives. These applications formed what
has been termed the "rehabilitative ideal" in criminology and criminal
justice. Medical models of disease and pathology were transplanted from
their indigenous public and private health settings and installed within
the coercive regimes of out coutts, prisons, and correctional facilities. The
agents of crime and violence were the target of secondary prevention sttat-
egies. As substantial recent reviews of these efforts have shown, this re-
stricted initial wedding of medical philosophies with criminal and penal
philosophies has had impoverished results (Martin, Sechrest, and Redner
1981; Sechtest, White, and Brown 1979).

Discontent with the rehabilitative ideal has recently turned many of out
colleagues to search for alternative ways to control serious behavioral out-
comes such as lethal and nonlethal violence. Proposals of deterrence and
incapacitation circulate widely and are undergoing continued close scrutiny.
These strategies have unclear feasibilities and uncertain magnitudes of effect
(Blumstein, Cohen, and Nagin 1978).

The time is propitious for public health perspectives to enter the arena
of disciplinary and theoretical thought about the etiology of violent conduct.
There ate now no cleat and strong positions about how to proceed in
containing and, perhaps in some cases, eradicating interpersonal violence.
The wisdom of many perspectives - particularly one such as your own
which has won many battles against injurious hosts, agents, and enviton-

ments - should contribute substantially to efforts to curb the advancement
of interpersonal violence.

As central to the public health approach as its conceptual and meth-
odological armaments is the position that health care is best learned, pet-
formed, and maintained when it is ingrained as part of individual and
community hygiene, as part of daily routines and salient perceptions of
what constitute good health practices. Preventive and control strategies
which do not enlist the routine cooperation of those who are to benefit
from these strategies can have some success but not as much as they might.
Both the American public and those health care practitioners charged with
securing the public safety and welfare must learn to consider violence
prevention and control as part of their daily requirements and responsi-

14


bilities. The American people must feel free to appeal to family life centers,
drop-in crisis centers, and in-home service programs, to name but a few
of out emerging responses to violence, without fear of social stigma, re-
probation, or sanction. Our nation must feel as comfortable controlling its
violent behavioral urges and practices as it does in controlling bacterial,
vital, and physical mechanisms of morbidity and death.

The responsibility to stand firm against interpersonal violence is not the
exclusive preserve and discharge of our contemporary public caretakers and
monitors - our law enforcers. Although criminal justice approaches may
have their place and effectiveness as part of violence control strategies -
such as the recent Minneapolis study of police response patterns to domestic
violence suggests (Sherman and Berk 1984) - these strategies do not enlist
the sensibilities and commitment of our communities. Public health care
has been a leader in taking steps to form alliances and networks to make
health concerns permanent public priorities and part of personal practices.
Winning the public to the cause of treating violence as a health concern
may well be, along with its research and methodological equipment, one
of the major contributions of public health services.

Many participants here today, who represent diverse disciplines, travel
in partnership to a common understanding of interpersonal violence and,
by virtue of that understanding, seek to treat the causes and correlates of
that violence. But there ate barriers to teaching this common understand-
ing, many of which have been articulated by the contributors to the wotk-
shop Sozrm Book.

An Expanded Data Base

Epidemiological approaches to describing and analyzing violence require
reliably gathered and valid information. Particularly important ate longi-
tudinal data that span the lifecourse of subjects and reflect the many settings,
domestic and otherwise, which influence the origins and development of
violent behavior. These data must include persons who are subjected to
violent assaults and those who are responsible for assaults as well as the
situations in which assaults occur. In the lexicon of health care, basic,
extensive, and quality information is needed about hosts, agents, and en-
vironments. With these data, the progression and vicissitudes of violent
careers, as we now refer to them in our criminological pursuits, can be
examined effectively and precisely.

The collection and maximum utilization of primary data sources is, then,
a priority which needs continued and substantial support. Because lifespan
data often demand substantial time for collection and analysis, practitioners

15


who seek to use and apply the fruits of such research data must be patient
while they are gathered and analyzed. Moreover, to realize out goal of
diminishing the ravages of interpersonal violence, solid evaluation of pro-
grams which respond to these physical onslaughts must be initiated. All
who are here should recognize this need. Greater efforts to conduct proper
assessments of violence reduction and control modalities are integral to
rational efforts to establish and perpetuate those modalities which, in a
word, work.

Law and Liberty

Our analytical and social service initiatives must be joined to consid-
erations of law and justice. Complex issues of personal and collective ftee-
dom and protection collide in the arena of violence legislation about
dangerousness. Protective service action exemplifies this legal tension. What
are the proper limits of intervention? At what point may health care prac-
titioners legally and coercively enter domestic settings? When might such
entry constitute an unlawful intrusion, a violation of freedom and liberty
that may be mote deleterious than those practices which the empowerment
legislation was intended to curtail?

No less controversial and complex are legal issues about how to control
responsibly the explosive armaments which take so many lives each year.
We must acknowledge that firearms are used to kill people in the United
States in frighteningly great numbers. Socio-cultural differences aside, the
ready accessibility of firearms in the United States and their near inacces-
sibility in Japan probably play a major role in the IO,7 15 criminal homicides
by firearms in the United States in 1980 in contrast to only 48 in Japan.
Without this mechanism of death so generally and easily accessible, people
would not kill, and people would not die, as frequently as they do.

The resolution of these and other legal questions is a pressing concern
which many here in attendance have already begun to address. More at-
tention to these issues will be required as public health care focuses on
physical violence and dangerousness.

To meet the needs of data preparation and analysis, of program evalu-
ation, and of framing informed and effective legislation, greater public
health efforts to confront violence must be focused and collective.
Surgeon General Koop's challenge to cleanse and to treat the national
wounds of out present violence - a challenge he has laid squarely before
each of us - can be met only if there is a broad-based, comprehensive
agenda and an alliance of participants. Initiatives must be clearly articu-
lated, feasible, and nationally coordinated for the optimum benefit to ensue.

16


The Surgeon General's office has been and will continue to be a seat of
leadership in that enterprise.

But violence cannot be countered by government alone. The strengths
of community and common cause ate also requited to promote health and
well-being in our land. An alliance between public and private sectors
should promote progress toward reducing violence. Some major private
sector initiatives, such as the Eisenhower Foundation, presently exist and
provide comprehensive plans for future action (Curtis 1985).

In summary, our common challenge is one of forging a national agenda
and alliance in response to interpersonal violence and, by so doing, to
promote and safeguard the general welfare. At the vanguard of this enter-
prise is the authority and good offices of out entrusted advocate of the
public health, the Surgeon General. Perhaps this workshop marks the
commencement of a dialogue which will culminate in a message from out
nation's chief public health officer about the clear and present danger posed
to the American people by violent conduct.

Toward achieving, in concert, the goal of forcing a decrease in out nation's
violence, we must act with vigor, imagination, and resolve.

References

Archer, Dane, and Gartner, Rosemary. Violence and Crime in Cross-National Perspective. New
Haven: Yale University Press, 1984.

Baker, Susan P., O'Neill. Brian, and Karpf, Ronald S. The lnjifry Fact Book. Lexingron,
Mass.: D.C. Heath and Company, 1984.

Blumstein, Alfred, Cohen, Jacqueline, and Nagin, Daniel, eds. Dererrennand Incupkfation:
Estimating the Effec of Criminal Sanctions on Cr& Rates. Washington, D.C.: National
Academy of Sciences, 1978.

Curtis, Lynn A., ed. American Violence and Public Poliq. New Haven: Yale University Press,
1985.

Gelles, Richard J. and Cornell, Claire Pedrick. lntimute Violence in Families. Beverly Hills,
Calif.: Sage Publications, 1985.

Martin, Susan E., Sechrest, Lee B., and Redner, Robin, eds. New Directions in the Reha-
bilitation of Criminal Offinders. Washington, D.C.: National Academy of Sciences, 198 1.

Sechresc, Lee B., White, Susan O., and Brown, Elizabeth D.. eds. The Rehabilitation of
Criminal Offemkrs: Problems and Prospects. Washington, D.C.: National Academy of Sci-
ences, 1979.

Sherman, Lawrence W. and Berk, Richard A. "The Specific Deterrent Effects of Arrest for
Domestic Assault." American Soc~ologicai Review. 49 (April 1984):26 l-72.

17


U.S. Deparrment of Health and Human Services, Public Health Service. He&by People:
The Srwgeon General's Report on Health Promotion and Disease Prmnrion. Washington, D.C.:
U.S. Government Printing Office, 1979.

  PromorinK Heah. Prevenmtin~ Disease: Objedves for the Ndion. Washington, D.C.:
U.S. Government Printing Office, 1980.

U.S. Department of Justice, Bureau of Justice Statistics. Criminal Virthizarion 1083,
Bulletin. Washington, D.C.: U.S. Government Printing Office, June 1984.

   The Risk of Violenr Crime. Special Report. Washington, D.C.: U.S. Government
Printing Office, May 1985.

U.S. National Commission on rhe Causes and Prevention of Violence. To Estahfish Justice.
to Insure Domestic Tranquility: Ftnul Report. Washington, D.C.: U.S. Government Printing
Office, 1969.

U.S. Surgeon General. Violenceasa Public He&h Problem. Sourcebook, prepared for the Surgeon
General's Workshop on Violence and Public Health, Leesburg, Virginia, October 27-
29, 1985.

Weiner, Neil Alan, and Wolfgang. Marvin E. `*The Extent and Character of Violent Crime
in America, 1969 to 1982," In American Violence and Pnbiic Policy, edited by Lynn A.
Curtis, 17-39. New Haven: Yale Universiry Press, 1985.

Wolfgang, Marvin E., and Weiner, Neil Alan, eds. "Surveying Violence across Nations:
A Review of the Literature with Research and Policy Implications." United Nurions
International Review of Criminal Policy: Violence Forum, forthcoming.

18


Violence and Public Health

Presented by William H. Foege, MD
Assistant Surgeon General, USPHS, and Special Assistant for
Policy Development, Centers for Disease Control
Monday morning, October 28, 1985

I can't pretend to tell you much about the problem of violence. You
come already schooled in the subject, convinced of its importance, and
concerned by its impact. I will instead make a few observations about how
this compares with other public health problems and what we can learn
from our public health experience regarding how to pursue the problem of
violence.

An Historical Preview

Throughout history, the two leading causes of early or premature death
have been infectious diseases and violence. Infectious disease control started
190 years ago with the work of Jenner, when he developed the first vaccine,
smallpox vaccine. Infectious disease control continued along with many
nonspecific social changes, such as better nutrition, better housing, and
education. In the past 50 years, we have returned to some specific tools,
including vaccines, antibiotics, and pesticides.

On the other hand, violence has defied the best minds in health, politics,
religion, and law enforcement, and therefore has often appeared to be
inevitable. This and other forms of fatalism must be actively opposed. That
we live in a cause-and-effect world is as true with violence as with infectious
diseases, an important observation for both public health people and
educators.

Another important observation is that public health is in the business
of continually redefining the unacceptable. This changes the social norm
which in turn changes the problem. For example, 35 years ago, polio was
the inevitable price of summer in this country. With the widespread use
of polio vaccine 30 years ago, the social norm in this country quickly
changed. However, for the hemisphere as a whole, the social norm has
been polio control or relatively low levels of polio disease. On May 14 of
this year, the Regional Director of the Pan American Health Organization
announced that polio would be eliminated from this hemisphere by 1990.

19


With that one announcement, the social norm changed, and it instantly
became unacceptable to have any cases of polio in this hemisphere.

This conference is an important step in redefining the unacceptable in
interpersonal violence. It is a major step in enlisting the public health
structure of this country in changing the social norm. It should be under-
stood that many have seen violence as being unacceptable just as many saw
polio as being unacceptable. But until recently, violence has not been
regarded as a public health problem. Rather, it has been viewed as a law
enforcement problem, or as a transportation problem, or a welfare problem.
Dr. Koop is largely responsible for putting this on the public health agenda.

Recent Developments

In 1977, a group began looking at morbidity and mortality in this
country to advise on the 12 most important things that could be done in
prevention. They made popular the notion of not only looking at the leading
causes of death but also looking at the leading causes of years lost before
age 65. While heart disease, cancer, and stroke lead the list of causes of
death, the leading causes of years lost prematurely are accidents, cancer,
heart disease, homicide, and suicide. Therefore, three of the five leading
causes of premature death are related to violence. It was because of this
finding that we started a program of violence epidemiology at CDC and
hired Dr. Mark Rosenberg who has training in both psychiatry and epi-
demiology to head that program.

In 1979, the Surgeon General published his book He&by People, out-
lining the 15 priority areas requiring national attention in prevention. Also
in 1979, the first meetings of health people from around the country were
held to develop the 1990 objectives, a set of over 220 specific objectives
of where the United States should be in health by 1990. These include
specific objectives on homicide rates, child abuse rates, and suicide, as well
as on specific risk factors. This national prevention strategy is a landmark
in public health, and it is important that violence is a part of the strategy.

In 1985, the National Academy of Sciences and the Institute of Medicine
published InjuT in America -A Continuing Public Health Problem. It pointed
out that injury, both intentional and unintentional, remains the major
unaddressed public health problem of our day. While injury accounts for
4.1 million years of life lost before age 65 each year, heart disease and
cancer combined account for only 3.8 million years lost before age 65.
Yet, we spend $1.622 billion per year on research for the latter and only
seven percent of that amount on injury research.

20


Basic to every successful public health effort has been the development
of an appropriate surveillance system. This was true of the public health
pioneers, such as Jenner, Snow, and Semmelweiss, who did limited but
rigorous surveillance of a microcosm; but it is also true of the institutional
pioneers who have developed surveillance of cities, provinces, and then
entire countries.

The first nationwide surveillance system for any disease in this country
was not instituted until 1950. That system was developed for malaria and
made the startling discovery that indigenous malaria had quietly disap-
peared from this country some time in the 1940s without being noticed.
We did not organize another nationwide surveillance program for five more
years. In 195 5, because of a problem with polio vaccine which still contained
virulent virus, a nationwide poliomyelitis surveillance program was launched,
literally overnight.

Global surveillance for a disease was not developed until the late 1960s
as part of the smallpox eradication program. While it may appear late to
develop violence surveillance programs, in fact, surveillance in general is
in its infancy.

Surveillance is essential if there is to be a concerted effort in violence
control. We must define all aspects of the problem, collect relevant and
correct data, analyze that data in order to define interventions, and measure
the impact of those interventions. There are no short cuts. While we are
beginning to get better mortality data by age, sex, time, and geography
for homicide, we are only beginning to understand the dimensions of
nonfatal outcomes. As Mark Rosenberg has pointed out, that may represent
an even larger social problem than mortality. And we are a long way from
knowing how best to use that information to suggest the generic changes
most likely to have a favorable impact.

The Context of Violence

While good national surveillance is one key lesson, another is the need
to understand violence in its broad context. Most certainly, we should view
intentional and unintentional violence together. The surveillance network
needs are similar; the risk groups overlap; the risk factors, such as alcohol
and depression, overlap; and the instruments, such as cars and guns, over-
lap. But in addition, violence is not limited to physical injury. Deprivations
of many kinds are forms of violence. Discrimination is a form of social
violence, as is poverty. Indeed, Gandhi once said that poverty is the worst
form of violence. And the threat of nuclear war constitutes a violent cloud
over all of us.

21


While study requires us to narrow the focus, just as we do when studying
the nervous system or the gastrointestinal system, this study must be done
within a conceptual framework that understands the broad scope of violence.
It is important to capture the momentum of nonviolent movements and
prevent fragmentation of our efforts. The recognition of the International
Physicians for the Prevention of Nuclear War for this year's Nobel Peace
Prize is a significant indication of anti-violence movements which should
be incorporated in the total effort.

Role of Health Departments

Health departments should be seen as crucial and essential but not
sufficient. This is a lesson learned in many areas, even in what is regarded
as standard public health. Health departments are simply not strong enough,
sufficiently influential, nor rich enough to carry out programs by them-
selves. Around the world, we see this with immunization programs which
become possible only when political leaders and others provide their sup-
port. In the United States, polio immunization rates were as low as 65
percent in 1977. It was not until the executive and legislative branches of
government became involved with the states and counties, as well as ed-
ucation departments, PTAs, volunteer groups, etc., that immunization
rates in this country went to 80 percent, 90 percent, and finally to 97
percent. This comes close to a program of perfection, but it could not have
been done by health departments alone.

With violence, it is even more important to have the largest diversity
of professional and volunteer groups possible if a significant impact is to
be realized.

What then should be the role of health departments? First, health de-
partments could assist to get violence into the mainstream of public health.
Public health could provide the constituency that anti-violence now lacks.
Second, health departments could be involved in problem definition, an area
of considerable experience and expertise. Third, health departments could
be involved in the education of politicians and those who could change
what is now done, education of children through the development of ap-
propriate curricula, and education of the public by providing information
to the media. Fourth, health departments should develop intervention strat-
egies and evaluate their impact. Fifth, health departments must work to
keep this interest from being a fad. They must develop the stabilizing
interest to sustain a search for answers into the future. This is particularly
true if early intervention efforts turn out to be misplaced.

22


It is .important for the Federal Government to provide leadership, as is
being done with this conference. But it is essential that you not wait for
the Federal Government to develop a program. Most health programs at
the federal level have evolved because of convincing demonstrations at local
levels. This was true for the immunization program which was built on
many private, local, and state demonstrations. One of the telling examples
is the use of child restraints in this country. The Federal Government for
a variety of reasons could not or did not provide leadership. A pediatrician
and local health officer in Tennessee worked at county and then the state
level to get the first child restraint law passed in Tennessee. In only a few
years, all states had followed the example.

It is important to promote a groundswell of trials, demonstrations, and
suggestions from private sources as well as local and state health depart-
ments. Many pilot projects of varied types increase the chance of funding
some interventions that are worth replicating. You force the federal estab-
lishment best by demonstrating something so compelling that it has to be
replicated (as with child restraints).

International Implications

Finally, remember the international aspects of violence. We saw the
disparity in homicide rates by country and the exceptionally high burden
of violence endured by many., Although the developing world is quite
correctly concerned with reducing its infectious disease rate, some Third
World countries are already losing more premature years to violence than
to infectious diseases. A broad perspective in studying violence and de-
veloping intervention strategies will serve the world most completely.

Smallpox is the only disease to have been eliminated from the world.
As a person interested in that program, as well as international health
generally, I can assure you that you are on the ground floor of something
more fundamental and ultimately more important than smallpox eradica-
tion. The single most important lesson of smallpox eradication was the
demonstration that it is possible to plan a rational health future. What
you are now doing is a step - a vital step - in planning a rational future
for combatting violence.

23


Plenary Session III

Interpersonal Violence: A Comprehensive
Model in a Hospital Setting - From
Policy to Program

Presented by Karil S. Klingbeil, MSW, ACSW
Assistant Professor, School of Social Work, and Assistant Administrator,
Director of Social Work, Harborview Medical Center, University of
Washington, Seattle

Monday morning, October 28, 1985

Over the past several years, there has been an increasing focus on famiily
violence: the issues, the characteristics, the components, the etiology, and
intervention/prevention strategies. This focus on violence comes at a time
when we have evidenced dramatic changes in the health of our citizenry.
Many successful advances in treating illness and communicable disease are
well known. The attention to traumatic injuries, then, and the development
of major emergency facilities and trauma centers across the nation have
literally forced health care providers to deal with all types of catastrophic
injuries. Included are trauma injuries from interpersonal violence, both
intra-family violence and extra-family violence. Gunshot wounds, knifings,
physical beatings from other "lethal" weapons, sexual assaults, elder abuse,
and the psychological aftermath plague the provider. The picture that has

25


emerged is a frightening one. Clearly, family violence is a major public
health concetn and requires a community response.

As with most health care issues, clinical demands and frustrations precede
the scientific explorations, and family violence has followed this pattern.
Particularly evident over the years has been the frustration of emergency
room personnel as physical injuries from family violence have dramatically
escalated, and police, medics, and others have brought victims by the
thousands for emerging care. Many have literally been saved from "death's
door," while others have not been so lucky. Even those "saved" often return
to the precarious environment from whence they came, only to repeat their
journeys to the emergency facilities, much to the disgust and ongoing
frustration of the health care, criminal justice, and social service systems.
Further, while emergency medicine has become a certified medical specialty,
emergency room personnel are still ill-prepared to deal with the emotional
and psychological impact of family violence. Emergency rooms also function
as social service agencies after 5:00 pm and on weekends, when most
agencies are closed and victims of violence gravitate to emergency rooms
for psychological as well as physical attention. Whether emergency room
staff are prepared or not, they must deal on a round-the-clock basis with
all aspects of interpersonal violence.

Priority Populations

Harborview Medical Center, founded in 1877, is a 340-bed tertiary care
teaching hospital affiliated with the University of Washington in Seattle.
From its inception, Harborview has served the indigent medically ill of
King County. Its priority populations, announced by the Board of Trustees
in 1984, are persons in the King County jail; mentally ill patients, par-
ticularly those treated involuntarily; persons with sexually transmitted dis-
eases; substance abusers; indigent patients without third-party coverage;
non-English-speaking poor; trauma patients; burn patients; and those re-
quiring specialized emergency care (victims/perpetrators of violence).

Harborview Medical Center is also the major emergency facility in Seattle,
King County, and the Pacific Northwest. Most medical, psychiatric, and
psychosocial emergencies are brought to Harborview's Emergency Trauma
Center (ETC). Specific county commitments with the Division of Human
Services, including the Involuntary Treatment System (ITS) and the Di-
vision of Alcohol Services (DAS), bring the acutely disturbed psychiatric
patient and the excessively intoxicated patient for care. In addition, because
Harborview is a designated regional trauma center for the Pacific Northwest,

26


it provides care to the majority of multiply injured patients in Seattle and
surrounding environs, including the states of Washington, Alaska, Mon-
tana, and Idaho (referred to as the WAMI region). Annual traffic through
the ETC averages 40,000 visits in a city and county with a combined
population of 1.3 million.

It was from this clinical experience, coupled with an interest and com-
mitment to help as well as to prevent, that the Harborview Medical Center
project on interpersonal violence developed. The results of violence are most
frequently treated in hospital emergency rooms. Thus, the emergency room
has a unique opportunity to identify, intervene, assess, and treat interper-
sonal violence. The emergency room provides access to a population that
often is too frightened or ashamed to seek assistance from traditional social
work agencies; these patients seek the anonymity of a large, busy, often
impersonal health facility (Clement, J., unpublished paper, 1985).

The Social Work program in the emergency room began in 197 1. One
of the goals was to evaluate needs of the emergency room population and
to develop programs sensitive and responsive to those needs. In the next
decade a series of problem areas were identified and clinical protocols for
intervention initiated. The Social Work Director and the Medical Director
of the emergency room wanted very much to provide services to victims
of violence and provide leadership in the area of interpersonal violence
throughout the city, county, and state. The goal was to define the health
problems of a patient not just by the presenting symptom but by the
primary diagnosis. This meant that a women's broken arm may need to
be explored as a case of domestic assault, that a seizure or pancreatitis may
indicate a need to explore the patient's alcohol use, or that a straight wrist
laceration might require exploration as a suicide attempt.

Six Different Protocols

The clinical protocols estabiished a standardized model of detection,
assessment, and intervention specifically for victims of interpersonal vio-
lence. They now include the Child Abuse Protocol, the Adult Abuse Pro-
tocol (wife battering, spouse battering, partner battering), the Sexual Assault
Protocols (including incest victims, male and female), and the Elder Abuse
Protocol. The Grief Reaction Protocol addresses services to family members
of suicide and homicide victims. The Psychiatric Evaluation Protocol pro-
vides services to patients with a psychiatric illness or alcoholism who have
been violent or who have the potential for violence and are "at risk." The
beginning of the intervention process is dictated by "criteria for involve-

27


ment" by the social worker. It temains imperative that the criteria be as
broad as Possible, rather than include only those persons who are clearly
identified as victims (Clement, J., unpublished paper, 1985). This initial
approach is the key to detection of all problems of family violence and sets
the scene for early intervention and prevention.

(For additional information on the Social Work program in the emergency
room, the reader is referred to "Social Work in the Emergency Room,"
Clement, J. and Klingbeil, K. in Health andSocial Work, November, 1981
and "Emergency Room Intervention: Detection, Assessment, and Treat-
ment" by Klingbeil, K. and Boyd, V. in Battered Women and Their Families,
Springer Publications, 1984.)

This paper presents a comprehensive model for handling interpersonal
violence in a hospital emergency room. The goal is to recognize, detect,
assess, and treat all forms of violence against persons. This model, while
initially established in a hospital-based emergency room, is applicable and
replicable in other settings as well. Special focus is on tertiary and secondary
prevention; however, the model does address primary prevention of inter-
personal violence as an overall but often elusive goal. Complementary to
the model is the necessity to consider allocations of personnel, including
support staff, other budgetary considerations, and space allocation.

These are the steps for development of the comprehensive model.

1. Policy Statement

The first step is the clear articulation of a policy statement sanctioned
by the governing board or executive body of the institution. This is critical
for any program in interpersonal and family violence. Myths and personal
judgments continue to cloud the detection of violence between relatives,
friends, acquaintances, or strangers. A policy statement demonstrates com-
mitment, sets priorities of staff time and resources, and requires the admin-
istration, through the budgetary process, to allocate monies to an
interpersonal violence program.

Institutional commitment to a policy of non-violence is a major step
toward primary prevention and is as important to staff as to clientele.
This is an example of a policy statement:
"Harborview Medical Center (Faculty, Staff, Departments) acknowledges
a responsibility in the tertiary, secondary, and primary prevention of vio-
lence. This includes the detection, assessment, and diagnosis of all aspects
of interpersonal violence, the identification of high risk individuals and

28


groups, and the development of tesource networks and/or primary preven-
tive efforts as resources Permit.

"The policy addresses two major areas:
A. Intra-Family Violence
1. Spouse battering         5. Incest (child sexual abuse)
2. Wife battering        6. Sibling abuse
3. Marital rape            7. Elder abuse
4. Child abuse         8. Abuse of parents by children
B. Extra-Family Violence

All forms of violent acts against another person not related in an
intimate situation.

`Suicide attempts (and homicides) are frequently present in the above
categories and require the use of the Psychiatric Protocol for assessment
purposes. The interventions may differ, but sensitive and nonjudgmental
assessment and diagnosis is imperative. It is important to note that the
major difference between A. (Intra-Family) and B. (Extra-Family) is in the
definition of the relationship: i.e., violence occurring in the context ot
absence of intimacy."

The appointment of a hospital-wide committee on interpersonal violence
is detailed in Step 3 (see below), but could be included as part of a policy
statement.

2. Background/Justification Data

After the policy statement comes the justification of the program, with
appropriate background and substantiating information. This includes in-
formation on specific problems, such as child abuse, wife battering, suicide
attempts, etc. This second step also requires a definition of terminology,
including the kinds of abuse and the distinction between abuse and bat-
tering. Abuse occurs in the physical, psychological, sexual, and enviton-
mental contexts. Additionally, there should be a statement of philosophy,
principles, and the identification of high risk individuals or groups by
critical identifiers for diagnostic purposes.
Thus, step two addresses the following key areas:
A. problem statement
B. definition of terms
C. philosophy

D. principles: standards of practice

29


E. magnitude of the problems - statistics
F. demographics, if applicable
G. behavioral characteristics or descriptions
H. identification of high risk individuals/groups
I. bibliography and references

This second step clearly articulates the justification and philosophy for
a violence program in the emergency room. In other words, anyone reading
Step 2 would understand the extent of the problem, the need for inter-
vention, methods of intervention, etc.

Philosophy is important to any program, particularly one where there
are varying opinions and myths that prohibit appropriate diagnosis and
intervention. A comprehensive philosophy should include a statement on
non-violence as a way of life - that violence is not justified in any rela-
tionship except in self-defense, Additionally, it should address the contin-
uum of violence, from child abuse to elder abuse. It should clearly address
prevention and lay the groundwork for education of client and professional.

Definitions can be relatively simple: for example, ". . . family violence
is defined as behavior toward a family member that would evoke legal
action if directed toward a stranger." ("Family Violence Principles of In-
tervention and Prevention," Jean Goodwin, M.D., HospitaL and Comnmnity
Psychiatry, Oc t . 1985). Or family violence includes any act of force or
coercion against another person without his or her permission.
Additional philosophical statements can deal with treatment strategies,
advocacy, community resource building, and networking.

3. Procedures

The third step in this model is the development of specific, recommended
approaches to various problem areas in interpersonal violence. Obviously
the emergency room would have quite specific and detailed protocols per-
taining to interpersonal violence, while other departments in the hospital
might not. All departments, however, should have written procedures in
concert with the overall hospital policy. As an example, a nursing depart-
ment policy/procedural statement might address staff development and
inservice training in support of the overall hospital violence policy.

The third step would include protocols, if the department is involved
in "hands on" tertiary care. Otherwise, a statement of how department
policies mesh with hospital policy will suffice.
A sub-step is the development of literature, including brochures and
pamphlets on community resources as handouts to patients and their fam-

30


ilies. Copies of regulations and/or the law should also be available, either
attached to a specific protocol or referred to in a department procedure.
Both brochures and copies of appropriate laws might be included in the
patient's admission packet, but would in any case be available in the
emergency room as handouts.

An overall multidisciplinary hospital committee on interpersonal violence
should be established. This committee could assure continued attention to
protocols, referrals, resources, and resource allocation (including staff time,
and budget). The committee should review hospital policy and update it
as needed. Additionally, the committee could focus on political issues in
the community, including public policy issues, statewide as well as local
funding issues, and environmental trends. Secondary and primary preven-
tion involve activities well beyond direct service, such as advocacy and
testimony regarding proposed legislation. A hospital committee can provide
leadership through legislative action. An interdisciplinary or multidisci-
plinary hospital committee can advance staff training on various levels,
such as employee orientations to "Violence Rounds," a major educational
pathway.

4. Protocols

The fourth step includes the development of specific clinical protocols
for use in the emergency room. The clinical protocols include:
A) Adult Abuse Protocol     E) Elder Abuse Protocol
B) Child Abuse Protocol    F) Psychiatric Evaluation Protocol
C) Sexual Assault Protocol    G) Alcohol Protocol
D) Incest Protocol      - H) Grief Reaction Protocol
Protocols should convey a clear commitment to exemplary, non-judg-
mental patient care. (See Klingbeil, K. and Boyd, V., Battered Women and
Their Families, Springer Publishers, 1984). This is especially important for
standardizing a level of care regardless of previous staff training.
The protocols should include all laws that apply to crimes of violence,
reporting requirements, and victim compensation, if applicable.

5. Resource Management

Step 5 calls for the establishment of a resource "bank" or network of
community agencies to which victims, families, and perpetrators may be
referred. This can involve the development of new programs within the
hospital and/or community as needs arise and are identified. This important

31


step extends the boundaries of the hospital into the community and develops
an effective "safety net" for patient care. Conversely, the community comes
into the hospital.

Resources can be identified in a number of ways but should include the
following:

- Criminal justice system for reporting and investigative purposes, as
well as treatment planning.

- Social service system for victims, perpetrators, and children; includes
mental health, alcohol, resources, and self-help. Crisis to long-term
  care facilities should be identified.

- Advocacy and legislative groups, including national professional or-
ganizations, such as AMA, APA, APsyA, NASW, ANA, and state-
wide organizations.

- Religious community
- Welfare agencies
- Health care system
- Educational community

6. Organizational Component

The sixth step concerns the organization of an interpersonal violence
program. Specific areas are as follows:
A. Population served
B. Practice and Standards by Discipline
C. Supervision - Peer Review Leadership
D. Knowledge and Skills
E. Protocols - Clinical Aspects
F. Program Development
G. Administrative Structure and Staffing
H. Demographics and Community Trends for the Future
I. Budget

Extra-Family Violence

So far the focus has been on intra-family violence issues. Now let's turn
to extra-family violence. To the six steps delineated above we would add
the identification of high risk populations in regard to extra-family violence.
The identification of high risk individuals or groups seen in the emer-
gency room is important in secondary prevention. Clinical impressions tell
us that many individuals, particularly those involved in extra-family vio-

32


lence episodes, have previously been seen at hospital and health care set-
tings. To identify these individuals and to intervene prior to a violent act
is the purpose of secondary prevention.
These are some of the high risk categories:
1. Psychiatric diagnosis such as depression
2. Alcohol diagnosis (including DWI) and substance abuse
3. Behaviors associated with loss, grief, death
  4. Isolation
5. Lack of support system
  6. Homelessness

7. Previous history of assault/suicidal behavior
8. Chronic unemployment

9. Presence or use of weapons, previous arrest for crime, etc.
10. Runaway
11. Single auto accidents
12. Psychosomatic complaints
This is a list of "red-flag" antisocial and delinquent behaviors. These
categories are important to early case finding and early intervention, since
these patients most frequently show up in the emergency room. Their
identification would be followed by the use of screening devices, such as
violence scales and/or inventories which are particularly useful to an emer-
gency room staff. Many scales and inventories in the trauma literature can
be adapted for interpersonal violence behaviors. Emergency room staff could
apply such scales to individual patients and hopefully begin to predict the
level of lethality in future violent episodes.

Summary

This paper illustrates the steps in a comprehensive model for the iden-
tification, assessment, and treatment of victims of violence in a hospital
setting. A crucial step is the use of clinical protocols which specifically
detail the detection, assessment, intervention, and referral procedures.
Various hospitals in the country have moved ahead to develop family
violence programs in their emergency rooms and outpatient clinics. Few
programs in hospitals have also included extra-family violence.
Once the extra-family violence groups can be identified through protocols
such as the psychiatric assessment or alcohol protocol, both assessment and
early intervention techniques can be addressed. Assessment and primary
diagnosis are imperative to early intervention. Strategies must be developed
to identify patients-at-risk and to promote listening, caring, and helping

33


for this highly vulnerable population. Education of staff is essential. Pro-
grams need to be developed that reach out to these people, who frequently
do not seek help in the early stages of trouble. Networking with social
agencies must be accomplished. Attention should be given to tracking
systems, since this population frequently "shops" for care (but confiden-
tiality issues must also be addressed).

It is clear, however, that much can be done to reduce violence in our
society without massive new resources. We must begin with the idea that
an approach found successful in intra-family violence can be adapted for
extra-family violence, too. Protocols can be developed, modified, and ex-
panded. Protocols also lend themselves to audit and quality assurance
accountabiliry.

Every hospital in this country should have a policy and procedural manual
on interpersonal violence. Lack of attention to this critical area can mean
more health care dollars poorly spent and many lives needlessly lost.

34


Interdisciplinary Interventions Applicable
to Prevention of Interpersonal Violence
and Homicide in Black Youth

Presented by Deborah Prothrow-Stith, MD
Assistant Professor of Medicine, Boston University School of
Medicine, and Attending Physician, Boston Youth Program
Monday morning, October 28, 1985

Interpersonal violence and its most devastating outcome, homicide, are
endemic in urban black areas with low socio-economic indicators. Those
who are most affected are young and male. Homicide is the leading cause
of death for black men ages 15-24 years at a rate of 72.5 for every 100,000'
and for black men ages 25-44 years at a rate of 125 for every 100,000.2
These rates are 7-12 times higher than homocide rates for the general
population. '

Non-fatal interpersonal violence occurs at rates that are at least a mag-
nitude higher than homicide and likely represents an even greater overall
cost to society. There is less adequate data on non-fatal interpersonal vio-
lence. Emergency room and school data are the best sources of rates for
non-fatal interpersonal violence. However, these rates are underestimations
because, as we know, many episodes of interpersonal violence are neither
treated in emergency rooms nor do they occur in schools.

The Northeastern Ohio Trauma Study measured the incidence of cause-
specific trauma by collecting emergency room data for the year 1977. The
study reported an assault rate of 862 per 100,000 population. The over-
representation of urban blacks of lower socio-economic status was dem-
onstrated in this study as well. The incidence rate for assault in the urban
black neighborhood was over twice the total incidence rate and up to six
times the lowest neighborhood rate."

School-based data are equally compelling. During the 1969-70 school
year, Seattle Public Schools had four assaultive injuries per 1,000 students.'
In the U.S. generally there are approximately 75,000 assaultive injuries to
teachers a year at a rate of 35 per 1,000." A November 1983 publication
from the Boston Commission for Safe Schools' reported a survey of four
public high schools revealing that 50 percent of the teachers and 38 percent
of the students reported being victims of a school-based crime during the
year. The overrepresentation of urban black students was evident in this

35


report as well. Black students were suspended at the rate of 17 per 100,
compared to a rate of 8 per 100 for white students. A large number of the
suspensions (30 percent) are for interpersonal violence.

Weapon-carrying behavior was also reported in this Boston survey. Sev-
enteen percent of the girls and 37 percent of the boys reported bringing a
weapon to school at some point during the school year.

Socio-economic factors are thought to account for this overrepresentation
of blacks among homicide victims. In a recent Atlanta study data that was
corrected for socio-economic status, using the number of people per square
foot of housing, no longer showed a racial bias." Urban black adolescents
are overrepresented among the poor with unemployment rates of 40-60
percent" and are overrepresented among the victims of fatal and non-fatal
violence.

The severity and urgency of the problem for urban black communities
dictates the need for appropriate and effective prevention strategies. The
possibilities for such prevention strategies were greatly enhanced by the
recent conceptualization of interpersonal violence as a public health problem.

Traditionally viole  e was viewed as only a law enforcement problem
which limited bot f
        he professional expertise and the variety of institutions
involved. The t ditional public health model attributes occurrence of dis-
ease to complicated interactions between the environment, the pathogen
(the agent that is responsible for the disease), and the host (the individual
with the disease). The traditional public health model has been applied to
unintentional injuries. The application of the model to violence prevention
offers a particular challenge because of the intentional nature of violence-
related injuries.

The public health interventions applied to other problems that have been
most successful are those that have manipulated the environment and have
had little dependence on changes in human behavior. Yet, when applied
to intentional injury, environmental manipulations can be expected to be
less effective. For example, a safety lock on the trigger of a handgun could
be expected to prevent handgun-related accidents; but this intervention
could not be expected to have that same effect on intentional shootings.

Altering the host (victim) and the pathogen (assailant) in this case to
prevent interpersonal violence and homicide is dependent on changing
human behavior, which is more difficult than altering the environment.
The goal in such manipulations is to make the host more resistant to the
disease, and the pathogen less virulent. Preventing interpersonal violence
in urban young black men requires an appreciation of the distinct simi-
larities between the victim and the assailant, as demonstrated by Ruth

36


Dennis, Ph.D. "' Her work compares three groups of black men ages 1%
34 who were 1) incarcerated homicide perpetrators; 2) victims of serious
assault (knife and gun wounds); and 3) randomly selected non-institution-
alized black men found through household sampling. Social and psycho-
logical profiles of each participant were done and the three groups were
then compared.

The victim and perpetrator groups were similar to each other; they were
distinguishable from the control group in that they had less education, had
experienced more juvenile detentions, were more likely to carry a gun, and
were more likely to have been in jail before. In addition to having similar
characteristics distinct from the control group, these two groups had more
participants exchange roles (victim vs. perpetrator) during the study. Be-
cause of this role exchange and the similarities between victim and per-
petrator, when the public health model is applied to interpersonal violence
the host and the pathogen become equal, and prevention strategies designed
to make the individual less likely to be involved in violence are applicable
to both.

These strategies designed to raise an individual's threshold for violence
are predominantly education and behavior modification techniques. Teach-
ing conflict resolution and using role play to practice alternatives to violence
are such strategies.

The tenuous application of the host, pathogen, and environment disease
model is not the most significant gain from the conceptualization of in-
terpersonal violence as a public health problem. Perhaps the most significant
gain is the potential application of a multi-institutional and interdiscipli-
nary model which has been applied to other public health initiatives. The
national campaign to reduce smoking is an example of such an initiative.
The media, health care institutions, public schools, job sites, health fairs,
and county fairs become the source of education, information, and incen-
tives. Product labeling and advertisement restrictions are a part of the
effort. This approach is applicable to interpersonal violence prevention as
well when it is understood as a public health problem. Health education
programs like the one I teach are only a piece of the total picture.

The Black Adolescent

Designing violence prevention strategies that are effective with urban
black adolescents of lower socio-economic status requires an understanding
of adolescence, of issues of race, and of poverty. I will not review all the
theories of adolescent development under the impact of race or poverty as

37


such, though I will offer a general outline of these issues as applicable to
the development of violent behavior.

Adolescence is that period of dynamic physical and psychosocial matu-
ration which is the transition from childhood to adulthood. The physical
changes are the growth and development of puberty. The psychosocial
changes include both cognitive maturation from concrete to abstract think-
ing and the mastering of specific developmental tasks. These are the major
developmental tasks:

1) Individuation from family with the development of same-sex and
opposite-sex relationships outside the family.
2) Adjustment to the physical changes of puberty with the development
of a healthy sexual identity.

3) Development of a moral character and a personal value system.
4) Preparation for future work and responsibility.
Failure to accomplish these tasks can result in significant dysfunction

for the adolescent, which can impair him as an adult. The tasks are ac-
complished simultaneously and are the major requisites for healthy adult-
hood. The experience of poverty and of racism can significantly hinder the
accomplishment of these essential tasks. The development of a healthy self-
identity requires a sense of self-esteem and a healthy racial identity, both
of which can be undermined by poverty and racism. Preparing for future
work and responsibility is a meaningness enterprise, when unemployment
rates are astonishingly high. Developing a sense of moral character and a
functional personal value system is also not easy, when television and the
street are the main sources of values.

What Is "Normal?"

One of the most difficult problems facing service providers for adolescents
is that of defining normal behavior. Normal behavior for adolescents in-
cludes a variety of experimental behaviors which at other developmental
stages would be abnormal. Defining normal is even more difficult in cases
where there is a subcultural experience. Claude Brown in his literary work
Man&id in the Promised Land describes such an experience:
"Throughout my childhood in Harlem, nothing was more strongly im-
pressed upon me than the fact that you had to fight and that you should
fight. Everybody would accept it if a person was scared to fight, but not
if he was so scared that he didn't fight."
The example clearly illustrates the dilemma. How much fighting is too
much? When is it problematic? Many would agree that violence in self-

38


defense is appropriate; yet, if a homicide results, would running not have
been a better response? On the other hand, in a violent world, is it not
healthier to defend oneself rather than be beaten or harassed?

Narcissism and Sexual Identity

There are several characteristics of adolescence which make a teenager
more prone to violence. One such characteristic is narcissism. Narcissism
helps the adolescent make the transition from family to the outside world.
Yet, this narcissism is also responsible for the extreme self-conscious feelings
of adolescents which make them extremely vulnerable to embarrassment.
The adolescent feels that he is always in the limelight and on center stage.
He is particularly sensitive to verbal attack, and it is nearly impossible for
him to minimize or ignore embarrassing phenomena. Another adolescent
characteristic that predisposes to violence is the transient stage of extreme
sexual identity, or "macho." Establishing a healthy sexual identity requires
transient stages of extreme femininity for girls and macho for boys. Macho
is often synonymous with violent. The image of a coward is a deadly one
for a male adolescent in this stage.

Peer pressure has been labeled the single most important determinant
of adolescent behavior. " This vulnerability to peer pressure, a normal part
of adolescence, facilitates the accomplishment of several of the develop-
mental tasks; yet, it is a characteristic of adolescence which enhances the
predisposition for violence. If fighting is the expectation of peers, as il-
lustrated in Claude Brown's quote, then an adolescent is often unable to
disregard those expectations.

Erikson12 describes a societal moratorium from responsibility that is
necessary during adolescence to allow the requisite experimental behavior
to occur without compromise of future options. Thus, the adolescent is
able to experiment with a variety of roles without making a commitment.
There is debate as to whether this moratorium occurs at all, yet many agree
that in the situation of poverty, it does not. The poor adolescent struggles
with developmental tasks without the protection of a societal moratorium.

The black adolescent has to develop healthy racial identity, in addition
to the listed developmental tasks. Contact with racism results in anger that
appears to contribute to the overrepresentation of black youth in interper-
sonal violence. Psychologist Ramsey Lewis used "free floating anger" to
describe anger not generated by a specific individual or event but from
global factors such as racism and limited employment options. " This anger
is the excess baggage that an individual brings to an encounter that lowers

39


his threshold for directed anger and violence. This concept is helpful in
that it attempts to account for the environmental and socio-economic factors
and not label the individual as deficient. The anger is normal and appro-
priate. Violence prevention is therefore designed to achieve a healthier
response to anger, not to eliminate the anger itself.

Violence prevention programs which are appropriate for adolescents de-
velopmentally and which have a realistic cultural context can be expected
to be effective. Developmentally appropriate programs utilize peers in ed-
ucation and counseling and reflect an understanding of the stages of ado-
lescent development. The cultural context has to acknowledge the violence,
racism, and classism that many such adolescents experience.

The problem of interpersonal violence among poor black adolescents has
been long appreciated by frontline service providers, and despite an incom-
plete understanding of the causal factors, prevention and intervention pro-
grams have been developed with moderate success. The majority of these
prevention programs are either based in a school or linked to a school
because of the captive audience. Mosr are interdisciplinary and multi-
institutional.

The Boston Curriculum

The Boston Youth Program is a comprehensive health care initiative for
adolescents funded by the Robert Wood Foundation". The health care
services are hospital- or clinic-based and the health education/prevention
services are school-based. A violence prevention curriculum developed for
tenth-grade health students is one of the health education services. The
Boston Youth Program curriculum on anger and violence has been instituted
in four Boston high schools and one community agency setting. To date,
approximately 500 students have received the curriculum. The curriculum
is designed to

1) provide statistical information on adolescent violence and homicide;
2) present anger as a normal, potentially constructive emotion;
3) create an awareness in the students for alternatives to fighting by
discussing the potential gains and losses from fighting;
4) have students analyze situations preceding a fight and practice avoid-
ing fights by using role play and videotape;
5) create a classroom ethos which is non-violent and values violence
prevention behavior.
The prevention curriculum is specifically aimed at raising the individual's
threshold for violence, by creating a non-violent ethos within the classroom

40


and by extending his repertoire of responses to anger. It acknowledges the
existence of societal and institutional violence and the existence of insti-
tutional racism. Students are not taught to become passive agents, but they
are expected to claim anger and become intentional and creative about the
responses to it.

Anger is presented as a normal, essential, and potentially constructive
emotion. Creative alternatives to fighting are stressed. The classroom dis-
cussion during one session focuses on the good and bad results of fighting.
The students list the results. The list of bad results is invariably longer
than the good list; thus, the need for alternatives. This exercise emphasizes
that fighting or not fighting is a choice and that the potential consequences
are important to consider when making the choice.

Role-playing a fight is a unique part of the curriculum. During this
session the students are asked to create a usual fight situation. The fight
is videotaped and analyzed for the buildup or escalation phase, the role of
the principal characters, and the role of the friends in the crowd. Video-
taping the role-play is useful for discussions. Provocative behavior is labeled
and alternative behavior is discussed. The focus of the discussions is the
demonstration and reinforcement of preventive behavior.

The IO-session curriculum has been evaluated using pre- and post-testing
in one of the high school settings." This controlled study involved four
tenth-grade health classes of 106 students (approximately one-third of the
IO-grade enrollment for the school). Two classes were assigned to the
experimental group, while the other two classes were the control. The
violence prevention curriculum was presented to the experimental group,
while the control students continued with the regular health curriculum.
Both groups were evaluated by the same pre- and post-test instrument
approximately 10 weeks apart. The instrument tested for both knowledge
and attitudes about anger, violence, and homicide.

Higher Post-Test Scores

The experimental group had significantly higher post-test scores than
the control group. There was no difference between the pre-test scores for
the two groups. Knowledge scores accounted for more of the change than
did the attitude scores, though the change in attitude was significant with
PC.0 1. These differences in scores represent the effect of the Violence
Prevention Curriculum.

Student questionnaires were used to evaluate the curriculum. Eighty-
seven percent of the students enjoyed or very much enjoyed the unit.

41


Seventy-three percent of the students found it helpful with handling depres-
sion, and 63 percent found it helpful in handling anger.

This demonstration project shows that students can be receptive and
enthusiastic about a curriculum on anger/homicide, and that a significant
impact on both their attitudes and their knowledge can be accomplished.
Further study must delineate the impact this curriculum has on behavior
and the longevity of the impact. These preliminary results indicate that
health education as a technique for violence prevention should be studied
further and that no harm is apparent from the effort.

Recommendation

I believe that a health education initiative ought to be part of a national
campaign to reduce interpersonal violence. Such an initiative could use a
standardized version of our curriculum, replicated in a variety of high
schools across the country. It would involve some teacher training and the
production of new audiovisuals. If possible, some sort of nationwide, large-
scale evaluation could be carried out, using pre- and post-testing for knowl-
edge, attitudes, self-report of behavior, and self-concept. In addition, we
would want to measure the longevity of the impact and the impact on
behavior.

References

1. Centers for Disease Control. "Violent Deaths Among Persons 15-24 Years of Age -
  United States, 1970-78." Morbidity and Mortality We&y Report, 1983; Vol 32:35
  p 453-457.

2. Alcohol, Drug Abuse, and Mental Health Administration. "Symposium on Homicide
  Among Black Males." Public Health Repom, November-December 1980. Vol 95:6
  p 549.

3. Centers for Disease Control. "Homicide." Morbidity and Mortality Werkfy Report, No-
  vember 12, 1982, vol 31:44 p 594.

4. Barancik. J. I. "Northeastern Ohio Trauma Study: I. Magnitude of the Problem."
  American Journaf of Public Health, July 1983, Vol 73~7 pp 746-5 1.

5. Johnson, C. J., er al. "Student Injuries Due to Aggressive Behavior in the Seattle
  Public Schools During the School Year 1969-70." American Journal of Public He&h,
  1974, vol 64 p 904.

42


6. Baker, S. P., Dicrz, P. E. "Injury Prevention - interpersonal Violence." Hrulthy
  Pu,p/r - Th Stqcon Grncrali Report On He&h Prontotron and Disrasr Prezwttion.
  Bat;kSrwrnc/ Prrpurs: U.S. Department of Health Education and Welfare Publication
  No. 79-55071A 1979 pp 7 l-74.

7. The Boston Commission on Safe Public Schools. Making Otrr &boo/s Safe /OT Learning.
  November, 1983 pp 12-16.

8. Centerwall, B. "Race. Socioeconomic Status and Domestic Homicide, Atlanta 197 I-
  72." Aturriun Jotwnal o/Pnb/ic. Huhh. 1984 vol 74: 18 1% 15.

9. Joint Center for Political Studies. "A Fighting Chance for Black Youth." Focur, Sep-
  tember, 1985 vol 13:`) p 4.

10. Dennis, R. E. "Homicide Among Black Males: Social Costs to Families and Com-
  munitws." PNBIK Huhh Reports, November-December 1980, vol 95:6 p 556.

1 1. Jessor, R., Jessor, S. L. ProlllrN Behavior and Psyc~5ororial Drwlopmmt: A Lon@rJinai
  Study oj Youth. New York: Academic Press, 1977.

12. Erickson, E. Identity. Yo/tth and CriGJ. New York: W.W. Norton, 1968.

13. Akbar, N. "Homicide Among Black Males: Causal Factors." Pubh H&b Rrportr,
   November-December 19X0. vol 95:6 p 549.

14. THE BOSTON YOUTH PROGRAM. Howard Spivak, M.D., director. Bosron City
   Hospital, 8 IS Harrison Ave., Boston, MA.

15. Prorhrow-Stith, D., McArdle, P., Lamb, G. A. "The Value of Violence Prevention
   Health Education m an Inner City School." Boston Youth Program, unpubltshed
   dara.

43


This Epidemic of Family Violence

Presented by Anthony V. Bouza
Chief of Police, Minneapolis, Minnesota
Monday morning, October 28, 1985

In our society the family has been the traditional source of strength and
stability. This sense of family was part of every immigrant group to these
shores, from the first groups, the English and the Spanish colonists, to the
most recent groups, such as the Central Americans and the Southeast Asians.
But we are beginning to get an idea that not all families are strong and
stable. In some, there may be abuse of one or another member, the wife
or the children or an elderly parent. There may be incest. All these kinds
of actions are crimes of violence. The outcomes involve pain and great
personal distress. But these abuses and acts of violence against children also
endanger society, since rhey are, in effect, acts that create tomorrow's adult
criminal.

This is particularly and painfully evident among teenage women who
become pregnant and have their babies, using them as a kind of ticket out
of the house and into the adult world. They are "children having children,"
and a great many of them simply can't handle it. Already the reports are
beginning to multiply of teenage mothers who have abused, severely beaten,
and even killed their babies during periods of depression or anger or frus-
tration. Of the babies that survive, many grow up to be the abusers and
killers of tomorrow. And thus is born the generational cycle of family
violence.

Some people use the term "monsters" to describe these babies who grow
up as sociopaths, a menace both to the community at large and to those
immediately around them. But I submit that the real "monster" in our
society may, in fact, be that teenage mother, who bears her child and raises
it, but is incapable of giving it a decent, peaceful family life, a life enriched
by mutual love and a mutual sense of responsibility. Instead, these are
children bred in chaos and violence; and they, in turn, breed their own
chaos and violence.

This development - or this revelation - of violence in the American
family, and outward from the family into the community, has had a pro-
found impact on women in our society. Once placed on a pedestal and
virtually worshipped, the American woman has been pulled off that pedestal

44


to become the target of street predators: muggers, rapists, and "Johns."
They prowl at night, a time which no longer can belong to a woman alone.
The apperires of these predators are whetted and rwisted by the pornography
industry, which is now doing billions of dollars worth of business in every
medium of communication, including telephone and cable television.
Women are enlisted or forced to take part in this industry, beginning with
prostitution. Most of the time, they are snared into the business as teenage
runaways. They have usually fled the sexual exploitation that begins right
in their own homes, where they are victimized by members or close friends
of the family . . . by fathers, step-fathers, brothers, and "uncles," real or
imagined. For too many girls, this victimization occurs before they are 12
years old. Once on rhe street, their flesh is bartered over and over again,
for years, until they have no sense of who they are, who they could have
been, or even who they might still be.

For women, the issue of control of their own bodies is critical, but it is
not an issue only for the prostitute or for the sexually victimized woman.
Among women with more socially acceptable careers or with families, the
issue re-appears as the abortion issue or as the marital rape issue. As
suggested by the title of the best-selling book on women's health, "Our
Bodies, Our Selves," if a woman does not control her own body, how can
she have control over her self-hood and her destiny? She can't. Once she
loses control over access to her own body, the cycle of abuse and violence
only gets worse. Prostitution escalates to disfigurement and rape, and
assaults escaiate to homicide, the ultimate and total denial of a woman's
body and self.

"Mad as Hell"

But women are fighting back through the feminist movement and the
drive for liberation. They are raising their own consciousness and the
consciousness of others, too. They are "mad as hell and they aren't going
to take it anymore" and they have vowed to "take back the night." Their
enemies are rape and pornography, which imprison women in a hopeless
cycle of abuse, degradation, victimization, and death. Dozens of new wom-
en's organizations have sprung up representing virtually every point across
the spectrum of health and justice, of politics and society. New institutions,
such as women's shelters, have become integral elements of the total human
resources of a community.

A year ago, in September 1984, the Attorney General's Task Force on
Family Violence published a report which gave strong support to any efforts

45


that could change the way police departments look at family violence. The
Task Force said that violent acts within a family are still criminal acts and
they must be treated as crimes. The victims must be protected and given
justice. The perpetrators must be arrested. The report indicated - and I
agree - that arrest is still our best leverage for correcting a situation,
including bringing the perpetrator into some kind of treatment.

For a woman, the arrival of the police is the time when she must bite
the bullet. She has to understand how our adversarial system of justice
works in order to take full advantage of it. For centuries women have been
raised to accept their fate as victims and therefore to think and act like
victims. if they were abused, they were led to believe that they somehow
"deserved" it. But those days have got to end for all women. And they,
in turn, need understanding and compassion from the police and the courts.
They need strong advocates. But no one is more powerful than a woman
herself. The woman/victim must use the system, must file a complaint,
and, the hardest part of all, she must come forward to testify.

Male Myths

For their part, the police and the criminal justice system must abandon
their convenient myths of male authority and power and must begin to
take seriously the woman who lodges a complaint against a batterer. Yes,
the police are changing, but they are still not effective in countering the
arguments and pleas of the batterer and the abuser. We've heard those
arguments a million times: that a man's home is his castle, not hers; that
she must've done something to deserve what she got; that she probably
"had it coming to her;" that they always kiss and make up; and they'll
have forgotten all about it by morning. Sure, she filed a complaint, but
we'll hold off signing it and see if she works things out like the others
usually do. And so on.

Today's police need to adopt policies which limit discretion to allow this
kind of thinking, policies which compel the arrest of the perpetrator or,
if there is no arrest, policies which require a report explaining exactly why.
The same thing applies to prosecutors and the courts. They, too, must
begin to treat this matter seriously, applying sanctions of every kind to
change the dangerous behavior of the batterer or the abuser and to protect
the life and health of the victim. Parole and probation officers must rec-
ognize domestic violence as a crime and, therefore, a violation of the terms
of probation or parole. And we need a re-evaluation of existing law, with
new provisions making it harder for the batterer to get away with threats

46


and intimidation. These and other psychological weapons can be as de-
structive to a woman as physical punishment itself.

The demonstration project in domestic abuse, which we conducted in
Minneapolis, revealed several things. First, we learned how important it
is for a woman victim to be helped very early in the process by a woman's
advocate. If they can be helped through those first few hours of horror and
trauma and confrontation, most women will then show the courage and
the intelligence to get protection and justice. We also became true believers
in the importance of the women's shelter. There had to be a secure place
to run to, a place where a woman will be understood, a place that doesn't
ask a lot of questions because all the questions have already been asked and
answered by the people already there to take her in.

Alcohol and Drugs

We also learned never to underestimate the possible role of alcohol and
drugs. Alcohol and drugs in a man's bloodstream will take the place of
love and reasonableness and responsibility and the healthy fear of unknown
consequences. And we learned that the best weapon in our arsenal is the
weapon of arrest. Get the perpetrator out of the situation, release the victims

- his wife, his children - from the prison of his terror. Dry him out.
If he's got a chronic abuse problem, get him into treatment.

That's where the medical profession comes into play. The police can't
do this job alone. We know that. The courts can't do the job alone. They
know that. We need the help of people like the ones here at this Workshop

. . . doctors, nurses, psychiatrists and psychologists, social workers, law-
yers, counselors . _ you are the people who can step in and treat and
prevent and protect. You are the ones who can help a woman and her
children rebuild their lives. Otherwise, the cycle of violence in that family
will continue to escalate. And finally someone will get killed. The death
of the victim - spouse, child, or parent - is the ultimate "kick," the
final degradation.

The new federal and state laws requiring the health and social service
professions to report any actual and suspected cases of abuse have been a long
time in coming. But now they're here, and I urge every member of those
professions to obey those laws, to report what they may believe to be the
abuse of a child or the victimization of any member of a family by any
other member. Such acts are cri'mes. Report them.
Violence of all kinds is reaching epidemic proportions in our society.
We've got to work together to fight back, because we will never have

47


enough police and judges and jails to stem the rising tide of violent crime.
Prevention is the only answer. But prevention comes in a variety of forms:
. It involves treatment for physical and mental health.
. It involves helping a person break away from a dependence on alcohol
and drugs.
. It involves social justice - better schools, safer housing, more jobs
for disadvantaged youngsters.
. It involves controlling the instruments of violence, such as handguns.
This may not be an issue that would ordinarily involve the Surgeon
General; nevertheless, while we're here together focusing on violence, I
must ask him to use whatever influence he may have to convince the
President and other members of the Administration to work for the total
outlawing of handguns.

More Research Needed

Finally, I want to encourage the people here and anyone else who hears
of this Workshop, that this is an area that still needs a great deal of research.
We have relatively few facts; what we have most are statistics, and those
are mainly drawn from arrest records and court records. But we don't know
enough about why domestic violence occurs or who the typical offenders
and perpetrators are. Until we get a more substantial body of research data
behind us, we're nor going to be able to do an effective job of treatment
and prevention. And by "we" I mean not only the police departments of
our country, but also the courts and the hospitals and the family service
agencies and the churches and all the different community agencies, public
and private, that can provide a healthful, positive influence upon the course
of American family life.

This Workshop is a very important undertaking by the Surgeon General
and I commend him and the U.S. Public Health Service for having taken
the initiative and doing it. I can assure you rhat this effort comes not a

moment too soon.
Thank you.

48


Plenary Session IV

Recommendations of the Work Groups

Tuesday afternoon, October 29, 1985

ASSAULT AND HOMICIDE: EVALUATION AND TREATMENT

            CHAIR: Fernando A. Guerra, MD, MPH
ADV~SORYCOMMITTEE MEMBER: David Nee
           RECORDER: Deborah Stevens
       PARTICIPANTS: David A. Heppel, MD
              Capt. Bartholomew T. Hogan, MC, USN
               Thomas L. Lalley

Charles S. Petty, MD
Deborah Prothrow-Stith, MD
Susan E. Salasin
Jose M. Santiago, MD
Marlene A. Young, PhD

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

o Violence in the United States has become so pervasive that ir can no
longer be usefully viewed only as a problem ofdisparate acts by individual
offenders. Violence is a public health problem because of the toll it exacts
in injuries and deaths, especially among young people.

49


o Public health has continually redefined its role so as to address more
effectively the changing needs of a changing nation. Public health now
needs to accept the challenge presented to our country by violence and
its consequences.
o Any solution to the problem of violence will require a total community
effort, in which health care providers can play a special role. The emer-
gency room is often the first contact a victim has with those professionally
charged to provide health care. That encounter may determine how well
a victim recovers from the emotional consequences of assault as well as
from the physical trauma.
. The health care system must help victims recover emotionally as well
as physically and must help prevent further violence. Too many victims
are victimized again and again; providers must be alert to the special
needs of those most at risk of becoming repeat victims.
. Our call is for a spirit in America that rejoices in our ethnic variety,
a spirit that protects all of our people as our most important resource
and legacy, and finally a spirit that no longer toIerates violence.

In the area of Eduration we recommend that . .

1 . . information about the particular needs of violence victims - actual
or potential, direct or indirect - and their communities should be part
of the education of any heaIth professional who interacts with violence
victims. (E- 1)

. . . the Public Health Service should encourage schools of medicine,
nursing, social work, osteopathy, and the allied health professions to
offer more and better training in the treatment and management of
victims of violence. (E-2)

. the Public Health Service and the health professions should en-
courage state licensure and national board certification authorities to
include in their examinations questions related to violence as a health/
mental health problem. (E-3)

. . leaders in the fields of health and mental health should actively
enlist the media, schools, and community agencies in educating the
public about violence as a heaIth problem. (E-4)

In the area of Ruearcb we recommend that . . ,

. . . the Public Health Service should support improvements in the
collection of data about direct and indirect victims of assault and hom-
icide, since at present there is so little reliable data on the numbers and
types of victims treated by the health care system. (R-l)

50


. . . 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)

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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

67


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

68


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)

69


. . 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;

72


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-

73


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;

74


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


doctors, nurses, social workers, teachers, court personnel, employee as-
sistance counselors, psychiatrists, police, clergy, and all other health,
social service, and criminal justice professionals. (E-42)
In the area of Research we recommend that

. . . the factors that aid in the prevention of spouse abuse should be
identified. (R-37)

. . research and demonstration projects should be designed for the
prevention of spouse abuse and woman battering. (R-38)
existing intervention and treatment programs should be evaluated.
iii9)

 the different dynamics and consequences of abuse for men and for
women - and the service implications of these differences - should
be identified. (R-40)

In the area of Services we recommend that . . .

. . health and social service personnel should uniformly define spouse
abuse as any assault or threat of assault by a social partner, regardless
of gender or marital status and whether or not they are present or former
cohabitants. (S-60)

. . the empowerment of women should be supported by expanding
their social and economic options before and after the identification of
abuse and by addressing such vital issues and services as pay equity, the
enforcement of child support orders, adequate and low-cost housing,
child care, and job training. (S-61)

. . . model protocols for spouse abuse and woman battering should be
used in health settings for the early identification of such abuse and for
aiding victims. (S-62)

. . . spouse abuse protocols need to be developed for secondary treatment
sites primarily concerned with alcohol and drug abuse, suicide preven-
tion, rape and sexual assault, emergency psychiatric problems, child
abuse, and the homeless. (S-63)

. . federal, state, and local initiatives to prevent child abuse should be
mandated to directly address spouse abuse and woman battering as well.
(S-64)

. . . the Regional Centers established under the 1984 reauthorization
of the National Center for Child Abuse and Neglect should have spouse
abuse and woman battering added to their charters and the National
Advisory Board on Child Abuse and Neglect should be appropriately
renamed (e.g., the National Advisory Board on Family Violence) and
its membership expanded to represent these linked concerns. (S-65)

76


. shelters should be supported and encouraged to meet the emergency
needs of a11 victims, including protection, housing, and violence. (S-66)

. . each governor should designate a state office or agency as the focal
point for programs and policies related to domestic violence. (S-67)

. . the criminal justice system must acknowledge rape and sexual assault
as crimes, regardless of the past or present marital relationship between
victim and perpetrator. (S-68)

. battered women need to be assured that the violence against them
will stop, and that they will receive equal protection under the law and
a swift resolution of their cases. (S-69)

. . Congress should make sure that the full protection of the law in
matters involving domestic violence is provided for all families living
within exclusive federal jurisdictions. (S-70)

. new programs in education, treatment, and counseling need to be
developed to help stop abusive men from committing further acts of
violence. (S-7 1)

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Plenary Session V

Response to the Recommendations

Presented by C. Everett Koop, MD
Surgeon General, USPHS
Tuesday afternoon, October 29, 1985

This Workshop may be a new departure, but the sheer number of victims

- some 4 million - who cry out for help each year demands a public
health response. If prevention is the business of public health, where better
to focus attention than on this scourge of violence that permeates every
level of our society - where victims live not only in fear and dread, but
they also desperately try to sort out the shame and the guilt and the fear
that competes with their feelings of love and loyalty to their families.
While our attention has been directed primarily at interpersonal violence
within the family, we seek to address the causes and effects of such violence
outside the family as well.

Because this is the first Surgeon General's meeting on the subject of
violence, the scope may be more diffuse than some would have wished.
We have focused on public health, with additional participants representing
the law, the criminal justice system, and social services. I would want the
next workshop to focus more directly on the partnership of health and
justice.

Your recommendations are just what I had hoped for. It should be
possible for individual health professionals as well as the leaders of major

79


health institutions and associations to understand and act on them. Several
themes do recur in the recommendations from among the 11 work groups:
education of the public on the causes and effects of violence, education of
health professionals as to better care for victims and better approaches to
violence prevention, improved reporting and data-gathering, some addi-
tional research, and increased cooperation and coordination - "network-
ing," if you will - among health and health-related professions and
institutions.

Senate Hearing

I will begin carrying out that first recommendation of public education
tomorrow when I lead off the witnesses at a special public hearing before
Senator Paula Hawkins' Subcommittee on Children, Families, Drugs, and
Alcoholism. I will also send your recommendations to the Secretary of
Education and will indicate your willingness to work with his Department
to get something accomplished in our public and private schools, colleges,
and universities.
As for professional education, in addition to a report in Pz~bli Htdth
Reports, I will post your recommendations on the Surgeon General's elec-
tronic bulletin board as soon as possible. The bulletin board, which is part
of the American Medical Association's computerized Medical Information
Network, or MINET, reaches about 26,000 physician subscribers.
I will also convey your concerns to many other professional groups, such
as the American Nurses Association, National Board of Medical Examiners,
Association of State and Territorial Health Officers, American Academy of
Pediatrics, and the National Association of Social Workers.
As for the recommendations for research, I will convey them to the
Assistant Secretary for Health and to the heads of the five PHS agencies
who have the legal authority and the funds to conduct research. Several
work groups have suggested new prospective, longitudinal studies of vic-
tims and families. Such studies are complicated and costly to mount. I
honestly do not know how my colleagues will react to that, but I will
certainly give them the suggestions.

I would also like to respond to some specific recommendations.
o You asked that the Surgeon Genera! undertake an informational cam-
paign about spouse abuse - something that I can and will do. I will
transmit to the American College of Obstetricians and Gynecologists
the recommendation for more sensitive evaluation and care for battered
spouses who are pregnant. That also has my strong support.
. Both work groups on rape were concerned about the need for additional

80


research and recommended that a conference be held specifically to sort
out what needs to be done. I endorse that suggestion and convey it to
the Alcohol, Drug Abuse, and Mental Health Administration. You also
called for greater interdisciplinary cooperation in the field of rape, and
I agree that it is absolutely essential.
. In reference to assault and homicide, I understand your emphasis on
paying special attention to the impact upon minorities. Rather than
responding now, I would first like to see how the recommendations
dovetail with those recently made by the Secretary's Task Force on Black
and Minority Health.
. A number of recommendations concerning child abuse and child sexuai
abuse might well receive a more appropriate response from the Depart-
ment's Office of Human Development Services, a co-sponsor of this
Workshop. I intend to stay in close touch with that Office, as you clearly
imply I should. I can say, however, that I agree completely with the
recommendation that the abused child be treated promptly according to
an evolving plan. The victim should not be seen merely as a pawn in
some legal chess game.

Meanwhile, the PHS Division of Maternal and Child Health is be-
ginning an aggressive public education campaign on child abuse and
child sexual abuse and in May 1986 will co-sponsor a conference on child
sexual abuse. The Division will also be disseminating materials related
to these problems; I will ask them to include the recommendations in
their mailings.

I'd like to add that I will carry the recommendations to certain other
groups, such as the American Red Cross, the Boy Scouts and Girl Scouts,
and the 4-H Clubs of America.

o From the day I was appointed in I98 1, I've chosen the role of advocate
for vulnerable, threatened older people in our society. I assure you that
I will speak to this issue of elder abuse as well. I will deliver the
recommendations on elder abuse to the Administration on Aging in the
Department of Health and Human Services. The AoA interacts with
about 1,200 centers on aging, so it is an important ally for getting broad
exposure to the recommendations in this area. I will also discuss research
in elder abuse with Dr. T. Franklin Williams, Director of the National
Institute on Aging.

One work group recommended, in effect, that the Federal Government
practice what it preaches. and I agree completely. Hence, I'm pleased
that we've had a strong delegation from the Department of Defense at
the workshop. They represent not only the policy function but also the

81


line function, the people who actually deliver health care to servicemen
and women and their dependents.

What PHS Can Do

Let me share what the Public Health Service itself can do, is doing, or
will do in respect to interpersonal violence. The National Health Service
Corps, for example, is a PHS organization of health care professionals
working in medically underserved areas, most of them remote rural areas
or distressed inner-city neighborhoods. The Corps will be absorbing as
many of the recommendations as possible into its continuing medical ed-
ucation program for the 3,100 NHSC officers in the field. And we have
agreement from the Indian Health Serivce that the same actions would be
useful for their personnel, too.

The 60,000 PHS employees are a cross-section of American society; they
also have their share of personal problems, for which we have an employee
counseling service. I understand that domestic violence will be receiving
more attention from that counseling service during the coming year, in-
cluding the establishment of a support group for battered women within
PHS.

I believe the recommendations will be especially significant for the Na-
tional Institute of Mental Health, which supports research in violence and
anti-social behavior. I'm sure your thoughts regarding trends and emphases
will be carefully studied by NIMH personnel and by the PHS people who
work with migrant health centers, community health and mental health
centers, state and local health agencies, and so on. I'd like them to have
a heightened awareness of interpersonal violence in the conduct of the
important grass-roots programs in public health.

Regional Follow-Up

Some of the participants are thinking ahead to follow-up activities to
this Workshop. Regional meetings and some educational programs are
being discussed. I hope that you will drop me a note about subsequent
developments in this campaign against interpersonal violence. For my part,
I pledge that my Office will put that information together for a 6-month
follow-up report and a 12-month report. I agree with the strong recom-
mendation of greater coordination and information-sharing within - and
among - the health professions.

A final word. The causes of interpersonal violence, especially family

82


violence, are complex, multi-faceted, and extend into the social and cultural
fabric of society. Sometimes the etiologic agent may be far removed from
the narrower realm of health care. However, any remedies undertaken by
a health official, including - and especially - the Surgeon General, must
be consistent with his actual sphere of responsibility and influence and
moral persuasion. Several recommendations - thoughtfully conceived and
vigorously presented - are nevertheless well outside that public health
sphere. But I want to assure you that, when and where feasible, I will
transmit those recommendations as the sincere concerns of participants of
this Workshop, even though they address social and political problems
well beyond the influence of our colleagues in medicine, nursing, public
health, psychology, and health-related social services and of the Surgeon
General and the Public Health Service.

As long as I am Surgeon General, those who are victims of violence in
this country will have a strong advocate in my Office.
Thank you.

83


The "Delphi Survey"

In the spring of 1985, in anticipation of "The Surgeon General's Work-
shop on Violence and Public Health" scheduled for late October, the Public
Health Service decided to incorporate a Delphi survey in its pre-Workshop
planning. The contractor was Survey Research Corporation.
Delphi surveys are designed to measure the collective wisdom of a group
of experts. The participants are asked a series of questions, or exposed to
the group averages, and are then invited to reconsider their positions. The
process continues until a consensus emerges.
PHS felt that a Delphi survey preceding the Workshop would be of
value on three counts:

1. It would give a sense of shared purpose to participants who had no
prior contact with each other.

2. It would serve to clarify positions in advance of the Workshop,
thereby shortening the time needed to explore viewpoints. The Work-
shop could, therefore, go directly into action the moment it convened.
3. It would help sustain interest in the Workshop during the inactive
summer months.

Everyone on the invitation list was invited to participate in the Delphi
and virtually all agreed: an unusually generous response.
Delphi I (the first iteration) was launched in June. It contained three
broad questions representing the Workshop's areas of interest.
Ql What is the role of education?
42 What should be done in research?
43 What should be done about the delivery of medical, health, and
   social services?

Under each question, there were statements that asked for agreement or
disagreement on an 1 l-point scale. There was also space to propose addi-
tional statements for evaluation by the group.
The substance of statements proposed twice or more were included in
Delphi II and III (the next iterations). Neither the Public Health Service
nor Survey Research Corporation proposed or vetoed statements. Delphi II
and III were, therefore, the products of the participants.

84


With Delphi III in late August, the concentrations were well established
and there were no additional statements proposed. The Delphi survey was,
therefore, over.

Results

Response to the survey statements is measured by an 1 l-point scale used
as a continuous variable from " 1" signifying total agreement to " 11" sig-
nifying total disagreement. The midpoint "6" is the neutral position.
Two statistics are used to describe the results.
The first is the mean, or arithmetic average. It is interpreted as follows:
   1-2 :   very close to complete agreement
  3-4 :   substantial or general agreement
  5-7 :   verging toward or in the neutral area
  8-9 :   substantial or general disagreement
  10-l 1:   very close to complete disagreement
The second is .ru@ovt feziel. This is the total number (of percent) on one
side or the other of the neutral position. The following is an example:

Scale Value               Number of
                Respondents
   1                       5
   2                      9
   3    AGREEMENT         36
   4                      25
   5                      5       Total above 6 is 80

   6    NEUTRAL             5

7                        2      Total below 6 is 15
8                      3
9    DISAGREEMENT        3
10                      4

11                      3

    Total               100

In the example, the positive (agreement) support level is 80, the negative
(disagreement) support level is 15. The neutral position is 5. A positive
support level of 80 is high, since a substantial majority shows some level
of agreement with the position.

The rnean and the support level taken together are usually an adequate

85


description of the results. In the few cases where they are not, the distri-
bution of the data will be given in the text.
The following results of the survey are shown in question/statement
order.

Ql  What is the Role of Education?

The set of 14 statements under this broad question focused mainly on
action recommendations. In the few instances where theoretical positions
were offered, such as "education can change the mores," there was a sig-
nificant but telatively unenthusiastic response. On the other hand, positive
support levels for training in recognition, reporting, and other situations
calling for direct action were all extremely high.

Qla  POLICE SHOULD BE TRAINED IN EFFECTIVE METHODS OF
    INTERVENTION.

The mean is 1.8 and the positive support level is 99%: an extremely
strong showing for this and the two related statements that follow.

Qlb  HEALTH PROFE~~IONAU SHOULD BE TRAINED TO RECOGNIZE Do-
   MESTIC VIOLENCE.

The mean is 1.6 and the positive support level is 100%.

Qlc HEALTH PROFESSIONALS SHOULD BE TRAINED IN VIOLENCE-RE-
    PORTING PROCEDURES.

The mean is 1.8 and the positive support level is 97%.

Qld  HEALTH PROFESSIONALS SHOULD BE TRAINED IN VIOLENCE INTER-
    VENTION PROCEDURES.

The mean is 2.9 and the positive support level is 95%: agreement with
the position but with some reservations. We speculate that these may have
to do with the practical consideration of danger to the intervening person.

Qle  INTRODUCE VIOLENCE PREVENTION IN FAMILY LIFE COURSES IN THE
    SCHOOLS.

The mean is 2.3 and the positive support level is 76%.

Qlf  EDUCATION CAN CHANGE THE MORES (AND SOCIAL NORMS) THAT
   DKTATE VIOLENT BEHAVIOR.

86


The mean is 4.1 and the positive support level is 81%. But there is a
substantial 38% cluster around the generally neutral 5-6-7 area.

Qlg EDLJCATICIN CAN LEAD TO BE~ER COMMUNICATION SKILLS AND
    THEREFORE LESS VIOLENT BEHAVIOR.

The mean is 4.0, with positive support at 83%: a slightly better showing
than the preceding statement, but in the same area of general agreement.

Qlh IMPROVE PUBLIC AWARENESS OF LEGAL RIGHTS AND AVAILABLE
    SERVICES.

With a mean of 2.7 and a positive support level of 98%, agreement is
unequivocal. The next statement, which proposes a method to achieve this,
is even more acceptable.

Q Ii  USE THE MASS MEDIA IN A POSITIVE EDUCATION PROGRAM AGAINST
   VIOLENCE.

The mean is 2.0 and the positive support level is 96%.

Qlj  TRAIN AND CERTIFV FORENSIC PSYCHIATRISTS AND PSYCHOLOGISTS.
The mean is 5.0 and the positive support level is 60%: a response that
tends toward the neutral position. Response to the next, related statement
is even more so. Several respondents wrote "why?" to both statements.

Qlk  TRAIN AND CERTIFV FORENSIC SOCIAL WORKERS.
The mean is 5.3 and the positive support level is 52%.

Qll HEALTH EDUCATION, COMBINED WITH POSITIVE MODELING AND
   SUPPORT FOR NON-VIOLENT RESPONSE, CAN LEAD TO LESS VIOLENT
    BEHAVIOR.

The mean is 3.9 and the positive support level is 85%: general but not
enthusiastic agreement.

Qlm  GIVE CHILDREN EXPLICIT EDUCATION IN NEGOTIATION TACTICS
    AND CONFLICT RESOLUTION.
The mean is 2.9 and the positive support level is 95% : a clear acceptance
of the position.

Qln  PROVIDE PROFESSIONALS DEALING WITH VIOLENCE WITH SENSI-
   TIVIT~ TRAINING AND IN-DEPTH CASE CONSULTATION.
The mean is 3.5 and there is a positive support level of 83%; thus, there
is general, but not total agreement.

87


42  What Should Be Done in Research?

The I6 statements under this question were a mix of specific projects

and generalized approaches. In general, the group showed strong support
for practical rather than theoretical projects and for the study of environ-
mental rather than biological factors in violence. For example, statements
that called for the development of intervention field models or for the
evaluation of existing programs had mean values of 2.6 and 1.9, while
those that dealt with verbal skills or the structure of genes had values of
5.0 and 7.7.

Q2a NEUROPSYCHOLOGICAL AND BIOMEDICAL AREAS HAVE BEEN
    NEGLECTED.

The response is neutral, with a mean of 5.8.

Q2b  ANALYSIS OF STRUCTURAL (ENVIRONMENTAL) PROBLEMS IS THE KEY
    TO BE~ER RESEARCH.

There is general support for the statement with a mean of 4.2.

Q2c  RESEARCH SHOULD BE FOCUSED ON THE MORE VULNERABLE, HIGH-
    RISK POPULATION GROUPS.

The mean is 3.7 and the positive support level is 85%, which indicates
a favorable position on the statement.

Q2d  DETERMINE THE FUNCTION OF Poop VERBAL SKILLS IN RELATION
    TO VIOLENCE.

The mean is 5.0 and the positive support level is 58%. a marginally
neutral response.

Q2e  DETERMINE THE RELATIONSHIP BETWEEN VIOLENCE AND THE ABUSE
   OF DRUGS AND ALCOHOL.

The mean is 3.0 and the support level is 93%. Evidently there is con-
siderable interest in exploring the drug-alcohol-violence hypothesis.

Q2f  THOSE DYING RESEARCH ON VIOLENCE SEEM TO KNOW LITIZE ABOUT
   IT.

The mean is 6.3 and the negative support level is 3 1%. Most of the
response-60%-is in the 5-6-7 neutral range. Clearly, the respondents
were not able to express a clear judgment here.

88


Q2g  PRIVACY LAWS HINDER RESEARCH ON VIOLENCE.
The mean is 5.6 and 52% are at the neutral (6) point. Some of the
write-in comments indicate that the subject is a mystery to many of the
participants.

Q2h MORE INTERDISCIPLINARY RESEARCH Is NEEDED.
With 95% positive support and a mean of 2.6, the response is unequivocal.

Q2i MORE RESEARCH ON INNATE CHARACTERISTICS, SUCH AS GENE
   STRUCTURE.

The position is generally rejected: a mean of 7.7 and a negative support
level of 72%. (See also the related Q2a.)

Q2j  CONCENTRATE ON APPLIED RATHER THAN PURE RESEARCH.
There is substantial agreement with the position at a mean of 4.1 and
a positive support level of 67%.

Q2k  DEVELOP FIELD MODELS OF EFFECTIVE INTERVENTION.
The positive support level is 97% and the mean is 2.6. There is no
doubt that the group is strongly in favor of this kind of pragmatic research.

421 INVESTIGATE VIOLENCE AS NORMATIVE BEHAVIOR.
There is substantial agreement with a 3.8 mean and a support level of
84%,.

Q2m  INVESTIGATE THE RELATIONSHIP BETWEEN STRESS AND VIOLENCE.
92% agree, with a mean of 2.8.

Q2n  INVESTIGATE THE ETIOLOGY OF COPING SKIU.
There is substantial agreement with a mean of 3.6 and 84% support.

420  DETERMINE THE RELATIONSHIP BETWEEN ABUSE IN CHILDHOOD AND
    HIGH RISK IN ADULTHOOD.

Strong agreement at a mean of 2.8 and a support level of 93%. The
importance of this research may be stronger than the statistics indicate,
since some who disagreed did so on the grounds that the relationship had
already been established.

Q2p  EVALUATE EXISTING PREVENTION AND INTERVENTION PROGRAMS.
100% support and a mean of 1.9 for this pragmatic approach.

89


Q3  What Should Be Done About the Delivery of Medical,
Health, and Social Services?

These 14 statements were extremely diverse, as they dealt with specific
actions and procedures. All the proposals were given varying degrees of
support, except for the location of shelters in or near hospitals, which was
viewed neutrally. Real enthusiasm, however, was reserved for the expansion
of shelter and crisis facilities, for bringing schools and the justice com-
munity into the violence prevention network, and for creating multidis-
ciplinary teams at the local level.

Q3a  CREATE A CENTRAL DATABANK FOR CHECKING AND SHARING Hos-
    PITAL RECORDS.

There is substantial agreement at a mean of 4.3 and a support level of
78%.

Q3b DEVELOP MORE SHELTERS FOR VKTIMS OF DOMESTIC VIOLENCE,
    BOTH ADULTS AND CHILDREN.

There is strong agreement at a mean of 2.9 and a support level of 93%.

Q3c  LOCATE SHELTERS FOR VICTIMS IN OR NEAR HOSPITALS.
The group is neutral at a mean of 5.S and 58% in the 5-6-7 scale range.

Q3d IMPROVE MEDICAL-SOCIAL SERVICES OPERATION BY DEFINING
    AREAS OF RESPONSIBILITY.

There is substantial agreement with the position at a 3.1 mean and a
93% support level.

Q3e IMPROVE THE QUALITY OF PERSONNEL ENGAGED IN EMERGENCY
    MEDICINE.

87% agree at a mean of 3.3.

Q3f  DEFINE TYPES OF EMERGENCY Rook PATIENTS WHO REQUIRE THE
   A%%TANCE OF A SOCIAL WORKER.
The mean is 3.2 and the positive support level is 9 1%.

Q3g  BRING SCHOLL HEALTH FACILITIES INTO THE VIOLENCE PREVENTION
    NETWORK.

Strong agreement at a mean of 2.2 and a 97% support level.

90


Q3h  CREATE MULTIIXSCIPLJNARY TEAMS AT THE LOCAL LEVEL.
96% support the position at a mean of 2.5.

Q3i  DEVELOP STANDARDS THAT DEFINE WHAT Is ABUSE OF OLD PEOPLE.
There is substantial agreement at a mean of 3.1 and a support level of
91%.

Q.3j  BRING THE JUSTICE COMMUNITY INTO THE VIOLENCE PREVENTION
   NETWORK.

100% agree, with a mean value of 2.0.

Q3k  IMPROVE THE QUALI~ AND AVAILABILITY OF SHORT-TERM CRISIS
   INTERVENTION FACILITIES.
99% agree. The mean is 2.0.

Q31  CREATE LOCAL COORDINATING BODIES TO PREVENT THE DUPLICA-
   TION OF SERVICES.

78% agree and the mean value is 3.7. Some write-in comment feared
this would mean further regulation.

Q3m  DEVELOP STANDARDS OF CARE FOR OFFENDERS.
With a mean value of 4.0 and a support level of 76%, agreement is
unenthusiastic.

Q3n  MAKE QUALI~ DAY CARE AVAILABLE TO ALL.
74% agree and the mean value is 3.6.

91


List of Participants

Faye G. Abdellah, RN, EdD, DSc. Deputy Surgeon General and Chief Nurse Officer,
USPHS, Washington, DC.

(R) Sergeant Jean Albright, USAF. Bureau Chief, Srrrm b Sfr&l, Bitburg, West Germany.

Carole Anderson, RN, PhD. Associate Dean for Graduate Studies, University of Ro-
chesrer School of Nursing. Rochester, NY.

Laura Anderson, MPH. Health Services Coordinator, Health and Human Services De-
partment, City of Berkeley, CA.

Margaret Long Arnold. Coordinator of Women's Activities, American Associatron of
Retired Persons, Washrngton, DC.

Constance Avery-Clark, PhD. Clinical and Research Associate, Masters and Johnson
Instrtute. St. Louis, MO.

Rosemary Barber-Madden, EdD. Associate Professor and Drrector, Maternal and Child
Health Program, Center for Popularion and Family Health, Columbia University, New
York, NY.

Amy C. Barkin, MSW, MPH. Drrector, Employee Counseling Service Program, USPHS,
Rockville. MD.

Judith V. Becker, PhD. Drrector, Sexual Behavior Chnic, New York State Psychiatric
Instttute, New York, NY.

Douglas J. Besharov. Adjunct Scholar, American Enterprise Institute. Washington, DC.

Captain Edgar R. Blount, MD. Special Assisrant for Medical Affairs, Office of the Assrsrant
Secretary of Defense (Health Affairs). Washington. DC.

Major Linda Boone, USMC. Family Programs Officer, Headquarters, U.S. Marine Corps,
Arlington, VA.

Anthony V. Bouza. Chief of Police, Minneapolis, MN.

Gary L. Bowen, PhD. Assistant Professor, School of Social Work, Universiry of North
Carolina, Chapel Hill, NC.

Lee P. Brown, PhD. Chief of Police, Houston, TX.

(R) Work-Group Rapporreur

92


Mary Pat Brygger. Executive Director, Domestic Abuse Project, Minneapolis, MN

o Ann W. Burgess, RN. DNSc. Van Ameringen Professor of Psychiatric Mental Health
Nursing, University of Pennsylvania School of Nursing, Philadelphia, PA.

Jane N. Burnley, PhD. Associate Commissioner, Children's Bureau, Washington, DC.

Martha R. Burt, PhD. Director, Social Services Research Program, Urban Institute,
Washington, IX.

John A. Calhoun. Executive Director, National Crime Prevention Council, Washington,
Ix.

Jacquelyn C. Campbell, RN, MS. Wayne State University College of Nursing, Detroit,
MI.

Elaine Hilberman Carmen, MD. Professor, Department of Psychiatry, University of North
Carolina School of Medicine, Chapel Hill, NC.

David L. Chadwick, MD. Senior Vice-President/Medical Director and Director, Child
Protection Program, Children's Hospital and Health Center, San Diego, CA.

Jane R. Chapman. Director, Center for Women Policy Studies, Washington, DC.

Danny Chin, MD. Acting Medical Director, South Cove Community Health Center,
Boston, MA.

Dante Cicchetti, PhD. Associate Professor of Psychology, University of Rochester, and
Director, Mt. Hope Family Center, Rochester, NY.

J. Jarrett Clinton, MD. Department Assistant Secretary of Defense for Professional Affairs
and Quality Assurance, OASD (Health Affairs), Washington, DC.

Anne H. Cohn, PhD. Executrve Director, National Committee for Prevention of Child
Abuse, Chicago, IL.

Jon R. Come, DSW. Assistant Professor. School of Social Service Administration, Uni-
versity of Chicago, IL.

o Theodore 0. Cron. MAT. Special Assistant to rhe Assistant Secrerary for Health and
rhe Surgeon General, USPHS, Washingron, DC.

Phyllis Old Dog Cross, RN, MS. Psychiatric Nurse Clinician, Regional Mental Health
Services, Indian Health Service, USPHS, Rapid City, SD.

Lynn A. Curtis, PhD. President, Eisenhower Foundation, Washington, DC.

Bruce Cushna, PhD. Associate Direcror. Developmental `Evaluation Clinic, Children's
Hospital, Boston, MA.

* Member of the Plannmg Commitree

93


Howard Davidson, Esq. Director, National Legal Resource Center for Child Advocacy
and Protection, American Bar Association, Washington, DC.

Jane Delgado, PhD. National Executive Direcror, COSSMHO (Narional Coalirion of
Hispanic Health and Human Services Organizations), Washington, DC.

Major Gloria Deniz, USAF Nurse Corps. Pediatric Nurse Practitioner, Wilford Hall
Medical Center, Lackland AFB, San Antonio, TX.

Ruth E. Dennis, PhD. Associate Professor. Meharry Medical College, Nashville, TN.

Sara Reed DePersio, MD, MPH. Chief, Maternal and Child Health Service. State De-
parrmenc of Health, Oklahoma City. OK.

Karla M. Digirolamo. Executive Director, Governor's Commission on Domestic Violence,
Albany, NY.

Lt. Joseph DiPaolo, MSC, USN. Head, Family Advocacy Program, Naval Medical Com-
mand. Washmgcon, DC.

Marlene Echohawk, PhD. Associate Magistrate, CFR Court of Indian Offenses, Oklahoma
Ciry, OK.

Jean K. Elder, PhD. Commlssioner, Adminisrrarion on Developmental Disabilities, Wash-
ingron, DC.

Robert A. Fein, PhD. Program Director, McLean/Bridgewarer Program, McLean Hospital,
Belmonr. MA.

Fern Y. Ferguson, MSW. Presidenr, National Coalition Against Sexual Assault, Easr Sr.
Louis, IL.

Harvey V. Fineberg, MD, PhD. Dean, Harvard School of Public Health, Boston, MA.

Paul J. Fink, MD. Medical Director, Philadelphia Psychiatric Center and Chairman,
Department of Psychiatry, Albert Einstein Medical Center, Philadelphia, PA.

David Finkelhor, PhD. Associare Director, Family Violence Research Program, University
of New Hampshire, Durham, NH.

Anne H. Flitcraft, MD. Assistant Professor of Medicine, University of Connecticut Health
Center. New Haven, CT.

William H. Foege, MD. Assistant Surgeon General and Special Assistant for Policy
Developmenr, Cenrers for Disease Conrrol. Atlanta. GA.

Peter W. Forsythe, Vice-President and Director, Program for Children, Edna McConnell
Clark Foundation, New York, NY.

Henry W. Foster, Jr., MD. Chair, Department of Obstetrics and Gynecology, Meharry
Medical School, Nashville, TN.

94


Shervert H. Frazier. MD. Dircccor, National Institute of Menral Hcalrh. USPHS. Rock-
v~llr. MD.

SuElIen Fried. Founder, STOP VIOLENCE Coalition, Shawnee Mission, KS.

Richard J. Gelles. PhD. Dean of Arrs and Sciences and Professor of Sociology and An-
thropology, University of Rhode Island, Kingston. RI.

Henry Giarretto, PhD. Executive Director, Instirure for Communiry as Extended Family-
Parents United, San Jose, CA.

Jean Goodwin, MD, MPH. Professor of Psychiarry and Director, Joint Programs, Medical
College of Wisconsin and Milwaukee County, Milwaukee, WI.

o Margaret T. Gordon, PhD. Director, Center for Urban Affairs and Policy Research,
Norrhwestern University, Evanston, IL.

(R) Christine Grant, RN. University of Pennsylvania School of Nursing, Philadelphia,
PA.

Ellen F. Greenberg, PhD. Adminisrrative Officer for Health Policy, American Psycho-
logical Association, Washingron, DC.

Nahman Greenberg, MD. Executive Director, CAUSES, and Member, National Advisory
Board on Child Abuse and Neglect, Illinois Masonic Medical Center, Chicago, IL.
Fernando A. Guerra, MD, MPH. Medical Director, Barrio Comprehensive Family Health
Center, San Anronio, TX.

Philip A. Harding. Vice President for Social and Policy Research, CBS Broadcast Group,
New York, NY.

lsadora Hare, MSW, ACSW. Senior Sraff Associate, National Association of Social Work-
ers, Silver Spring, MD.

Col. Jesse Harris, DSW. Consulrant to the Army Surgeon General. Social Work Service,
Walrer Reed Army Medical Center, Washington, DC.

o David E. Heppel, MD. Chief, Child and Adolescent Primary Care Branch, Division of
Maternal and Child Health, USPHS, Rockville, MD.

Jean Hilsman. Direcror, Family Policy Office of the Deparrment of Defense, Washington
DC.

Lee Ann Hoff, RN, PhD. Associate Professor, Northeastern University College of Nursing,
Bosron, MA.

Captain Bartholomew T. Hogan, MC, USN. Head, Psychiarry Deparrment, Naval
Hospital, Naval Medical Command, Berhesda, MD.

Helen V. Howerton. Director, Narional Center on Child Abuse and Neglect, Washington,
DC.

95


Peter A. Howland, MD, MPH. Director. West Virginia Universiry Child Prorecrion
Team, Morgantown, WV.

Janice Humphreys, RN, MS. Wayne Stare University College of Nursing, Detroit, Ml.

Juanita K. Hunter, RN, EdD. Chair, Cabinet on Human Righrs. American Nurses
Assoctation, and Clintcal Assistanr Professor, School of Nursing, State University of New
York, Buffalo, NY.

Terry Hunter. Executive Director, Association of American Indian Physicians, Oklahoma
City, OK.

Charles F. Johnson, MD. Dtrector, Child Abuse Program, Children's Hosptral, Columbus,
OH.

Ms. Eddie Bernice Johnson, RN, MPH. Vice President, Government and Community
Affairs, Visiting Nurses Association, Dallas, TX.

LaVohn Josren, RN, PhD. Director of Public Health Nursing, Stare Department of
Public Health, Minneapolis, MN.

Blair Justice, PhD. Chair, Standing Committee on Interpersonal Violence, University of
Texas Health Science Center, Houston, TX.

Arnold S. Kahn, PhD. Administrative Officer for Social and Ethical Responsibility,
American Psychological Association, Washington, DC.

Luella Klein, MD. Director, Maternal and Infant Care Project and Professor of Gynecology
and Obstetrics, Emory University School of Medicine, Atlanta, GA.

Karil S. Klingbeil, MSW, ACSW. Assisranr Professor and Direcror of Social Work,
University of Washington, Seattle, WA.

C. Everett Koop, MD. Surgeon General, USPHS, Washington, DC.

Jordan I. Kosberg, PhD. Professor of Gerontology, University of South Florida, Tampa,
FL.

o Thomas L. Ialley. Depury Chief, Cenrer for Srudies on Anri-Social and Violent Behavior/
NIMH, Rockville, MD.

Norman Landsem, MSW. Director, Social Services and Mental Healrh, Bemidji Program
Office, Indian Health Service/USPHS, Bemidji, MN.

Barry D. Lebowitz, PhD. Chief, Center for Studies of rhe Mental Health of the Aging/
NJMH, Rockville, MD.

Howard B. Levy, MD. Chairman of Pediatrics, Mt. Sinai Hospital and Medical Center,
Chicago, IL.

Sheldon Levy, PhD, MPH. Director, Behavioral Sciences, Pediatric Ecology Program,
Mt. Sinai Hospital and Medical Center, Chicago, IL.

96


Dorothy Otnow Lewis. MD. Professor of Psychiatry, New York University School of
Medicine, New York. NY.

Dodie Truman Livingston. Commissioner, Admmistration for Children, Youth, and
Families, Washington, DC.

Ann Maney, PhD. Center for Anti-Social and Violent Behavior/NIMH, Rockville, MD.

Terry W. McAdam. Program Director and Vice President, Conrad N. Hilton Foundation,
Los Angeles, CA.

(R) Lawrence T. McGill. Center for Urban Affairs and Policy Research, Northwestern
University, Evanston, IL.

o Robert G. McGovern, MD. Director, Division of Ambulatory Pediatrics, Southwestern
Medical School, University of Texas Health Science Center, Dallas, TX.

Laura Smith McKenna, RN, DNSc. Clinical Specialist in Psychiatric and Mental Health
Nursing, Universiry of California ar San Francisco, San Francisco, CA.

Ramona T. Mercer, RN, PhD, FAAN. Professor of Family Health Care Nursing, School
of Nursing, University of California at San Francisco, San Francisco, CA.

J. Ronald Milavsky, PhD. Vice President, News and Social Research, National Broad-
casring Company, Inc., New York, NY.

o Georgia K. Millor, RN, DNSc. Assistant Professor of Pediatric Nursing, University of
Rochester School of Nursrng, Rochester, NY.

William Modzeleski. Chief, Family Violence Program, Office for Victims of Crime,
Departmenr of Justtce, Washington, DC.

Commander Richard C. Moore, Jr., MD, MPH. Chief, Medical Operations Branch,
U.S. Coast Guard Headquarters, Washington, DC.

Suellen Muldoon. Assistant Director, Human Behavior Deparrmenr, American Medical
Association, Chicago, IL.

Karin Murray. Policy Coordinator, Office of Family Policy of the Deparrment of Defense,
Washington, DC.

Toby Myers, EdD. Director, Staff Development/Continuing Education, Houston Inter-
national Hospital. Houston, TX.

o David Nee. Executive Director, Florence V. Burden Foundation, New York, NY.

o Eli H. Newberger, MD. Director, Family Development Program, Children's Hospital,
Boston, MA.

David M. O'Hara, DASS. Director of Social Work, Kennedy Insritute. Baltimore, MD.

97


K, Daniel O'Leary. PhD. Professor of Psychology, Srate University of New York, Srony
Brook, NY.

William Oltman. Executive Assistant to the Assistant Attorney General. Office of Justice
Programs, Department of Justice. Washington, DC.

CR) Frieda Outlaw, RN. Veterans Administration Medical Center, Haverford, PA

CR) Barbara Parker, RN. Assistant Professor, Universiry of Maryland School of Nursing,
Catonsville, MD.

o Delores L. Parron, PhD. Associate Director for Special Populations, Alcohol, Drug
Abuse, and Mental Health Administration, USPHS, Rockville. MD.

(R) Laurie Anne Pearlman, MA. Psychology Department, Univcrsiry of Connecricut,
Storrs, CT.

Lee Pearson. Assistant Coordinator, Criminal Justice Services, Amencan Association of
Retired Persons, Washington, DC.

Charles S. Petty, MD. DIrector, Southwestern Institute of Forensic Sciences, and Chief
Medical Examiner of Dallas County, TX.

Lt. Rosemary Pezzuto, USCG. Chief, Family Programs SectIon, U.S. Coast Guard Head-
quarters, Washington, DC.

Karl Pillemer, PhD. Research Scienrist, Family Research Laboratory, Universiry of New
Hampshire, Durham, NH.

Marie Kanne Paulsen, PhD. Director of Training and Education, Center for Child
Development and Developmental Disorders (UAF). Children's Hospital, Los Angeles,
CA.

(R) Bruce D. Poulter. RN. Staff Office of the Director, National Health Service Corps,
USPHS, Rockville, MD.

Deborah Prothrow-Stith, MD. Assistant Professor of Medicine, Bosron University School
of Medicine, and Attending Physician, Boston Youth Program, Boston, MA.

Barbara Rawn. Executive Director, Virginia Chapter, National Committee for the Pre-
vention of Child Abuse, Richmond, VA.

Robert Ressler. FBI, VICAP, National Center for the Analysis of Violent Crime, FBI
Academy, Quantico, VA.

Glare Marie Rodgers, RN, CPNP, MSN. Pediatric Nurse Practitioner, Secretary, National
Association of Pediatric Nurse Associates and Practitioners, Annapolis, MD.

Reymundo Rodriguez. Executive Associate. Hogg Foundation for Mental Health, Ausrin,
TX.

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(R) Helen Rosenberg. Center for Urban Affairs and Policy Research. Northeastern Uni-
versity, Evanston, IL.

o Mark L. Rosenberg, MD. Chief, Violence Epidemiology Branch, Centers for Disease
Control, Atlanta, GA.

Sandra Rosswork, PhD. Technical Director, Navy Family Advocacy Program, Department
of the Navy Headquarters, Washington, DC.

Louis Rowitz, PhD. Professor of Community Health Sciences, University of Illinois School
of Public Health, Chicago, IL.

Robin Rushton. Legislature Assistant to Senator Paula Hawkins and Professional Staff
Member, Senate Subcommittee on Children, Family, Drugs, and Alcoholism, Wash-
ington, DC.

David A. Rusr. Executive Secretary, Office of rhe Secretary of Health and Human Services,
Washington, DC.

Susan E. S&sin. Depury Associate Director, Office of State and Community Liaison/
NIMH. Rockville, MD.

Jose M. Santiago, MD. Chair, Department of Psychiatry, Kino Communiry Hospital,
Tucson, AZ.

Douglas A. Sargent, MD, JD. Chair, AMA Advisory Panel on Child Abuse and Neglect,
Grosse Point Farms, Ml.

Johanna Schuchert. Executive Director, Parents Anonymous of Virginia, Inc., Richmond,
VA.

Theoharis K. Seghorn, PhD. Associate Administrator, Massachusetts Treatment Center,
Bridgewater, MA.

o Saleem A. Shah, PhD. Chief, Cenrer for Studies on Anti-Social and Violent Behavior/
NIMH, Rockville, MD.

Barbara Shaw. Chair, National Coalirion Against Domestic Violence, Springfield, IL.

Lawrence W. Sherman, PhD. Professor of Criminal Justice/Criminology, University of
Maryland, College Park, MD.

James C. Shine. Vice President, Prosecution Services and Research, American Prosecutors
Research Instirute, Alexandria, VA.

Jan Sinnott, PhD. Guest Scientist, Gerontology Research Center. Francis Scott Key Med-
ical Center. Baltimore, MD.

Gloria R. Smith, MPH, PhD. Director, Michigan Department of Public Health, Lansing,
MI.

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Marti H. Speighrs. Family Advocacy Program Coordinaror, Department of the Army,
Headquarters, Alexandria, VA.

Evan Stark, PhD. Assistant Professor of Health Care Administration, Rutgers University,
New Brunswick, NJ.

Robert L. Stein 11. Acting Director, Military Family Resources Center, Office of the
Assistant Secretary of Defense for Manpower, Reserve Affairs, and Logisclcs, Arlington.
VA.

Suzanne K. Steinmetz, PhD. Professor of Individual and Family Studies, University of
Delaware, Newark, DE.

George G. Sterne, MD. Chair, Committee on Early Childhood, Adoption, and Dependent
Care, American Academy of Pediatrics, New Orleans, LA.

Murray A. Straus, PhD. Director, Family Research Laboratory, and Professor of Socrology,
University of New Hampshire, Durham, NH.

Harry R. Tanner, MSW. Executive Director, Community Council of Greater Dallas, TX.

Robert ten Bensel, MD, MPH. Professor and Director, Program in Maternal and Child
Health, Universiry of Minnesota, Minneapohs, MN.

Joyce N. Thomas, RN, MPH. Director, Division of Child Protection, Children's Hospital
National Medical Center, Washington, DC.

(R) Sara Torres, RN. University of Texas, Austin, TX.

Major Henry F. Vader, USAF. Family Advocacy Program Manager for the Air Force
Surgeon General, Brooks AFB. TX.

Leonore Walker, PhD. President and Psychologist, Walker & Associares, Denver, CO.

R. pale Walker, MD. Associate Professor and Director of Social and Cultural Psychiatry,
University of Washington, Seattle, WA.

John B. Wailer, Jr., DrPH. Director, Health Department, Derroit. MI.

(R) Priscilla Kiehnle Warner. Center for Urban Affairs and Policy Research, Northwestern
Universiry, Evanston, IL.

Martin Wasserman, MD, JD. Director, Arlington County Department of Human Services,
Arlington, VA.

Vicki Weisfeld. Communications Officer, The Robert Wood Johnson Foundation, Prince-
ton, NJ.

Richardson White, Jr. Research Director, Police Executive Research Forum, Washington,
DC.

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Marvin E. Wolfgang, PhD. Professor and Director, Sellin Cenrer for Studies in Crimi-
nology and Crimmal Law. University of Pennsylvania, Philadelphia, PA

Bruce A. Woudling, MD. Consulrant, Ambulatory Forensic Medicine, Ventura, CA.

o Alan Wurtzel, PhD. Vice President, Broadcast Standards and Practices, American
Broadcasting Companies, Inc.. New York, NY.

Laura X. Executive Director, National Clearinghouse on Marital Rape-Women's History
Research Center, Berkeley, CA.

Marlene A. Young, PhD. Executive Director, National Organization for Victim Assist-
ance, Washington, DC.

101