Remarks as prepared; not a transcript
Vice Admiral Richard H. Carmona, M.D., M.P.H, FACS
United States Surgeon General
U.S. Department of Health and Human Services
Symposium on Family Violence: The Impact of Child,
Intimate
Partner, and Elder Abuse
Wednesday, August 6, 2003
"Family Violence as a Public Health Issue"
Thank you, Gene. (Eugene Regula, Supervisory Special Agent, National Center
for the Analysis of Violent Crime, FBI)
I’m grateful to FBI Director Robert Mueller for inviting me to this
Symposium.
I’m grateful to the FBI for recognizing that family violence is not just a
law enforcement issue, but affects all aspects of American society, including
public health.
President Bush has declared domestic violence ‘intolerable,’ and recently
signed the Keeping Children and Families Safe Act, which strengthens
state and local-level family violence prevention and treatment programs.
Health and Human Services (HHS) Secretary Tommy G. Thompson has said that
‘for the health of our country, it is critical that we stop this cycle now.’ So,
from the highest levels down through all of our different agencies, our
Department is committed to eliminate the insidious problem of family violence.
Shakespeare wrote "Men in rage strike those that wish them best."
That violence can occur in the most intimate of relationships: between a
husband and wife, between a mother and child, between a son and his elderly
mother, makes it extremely difficult to understand and to cope with.
We cannot look at the issue through the lens of criminal justice alone, or
law enforcement, or medicine, or education. It is problem within American
families of all racial and ethnic backgrounds and all socio-economic
backgrounds.
Victims are often afraid or unwilling to report it, and as a society we are
still too reluctant to discuss it. The silence and secrecy that still surround
the issue make it very difficult to face.
Personal Experience
As Gene mentioned, I have had first-hand experience in dealing with the
consequences of family violence, as a paramedic, registered nurse, law
enforcement officer and trauma surgeon.
I have seen first-hand the devastation caused by anger and violence in the
home. The women and children who are usually the victims of family violence pay
a high and sometimes even the ultimate price at the hands of the angry people in
their lives: physical trauma, emotional scars, and damaged self-worth.
My work on the local level in Arizona led me to be a founding member of the
Pima County Domestic Violence Council.
Now, as Surgeon General, I am part of the President’s team dealing with
family violence as a serious public health issue threatening women and children,
and sometimes men, of every age and from every racial and socio-economic
background in America.
Family Violence as a Public Health Issue
As you know, family violence is a broad term, and includes spousal or
intimate partner abuse, elder abuse and neglect, and child abuse and neglect.
Family violence can include physical assault and battery, sexual assault or
rape, and for children and the elderly, neglect. And therein lies one of our
problems – lack of public recognition of the depth and breadth of the problem.
There is an inter-connectedness among the various forms of family violence as
well. Studies have shown that men who frequently assault their wives also
frequently physically abuse their children. Mothers who are beaten are more
likely to physically abuse their children than mothers who are not abused.
We have heard the statistics about the prevalence of family violence.
According to the National Violence Against Women Survey, one out of four
women in the United States has been physically assaulted or raped by an intimate
partner; one out of 14 men also reported such experiences. Each year, an
estimated four million women are physically abused by their spouses or live-in
partners.
Of the women who are physically assaulted or raped by an intimate partner,
one in three is injured and requires medical treatment.
In the year 2000, an average of 2,400 children were victims of child abuse
each day, most in their own homes at the hands of a parent.
An average of three children die in this country every day because of child
abuse or neglect, over 1,000 each year.
While underreported, elder abuse is a concern as a large fraction of
America’s population continues to age. Most victims of elder abuse are older
women with a chronic illness or disability. Again, the most typical abusers are
spouses, adult children, or family members, those from whom one would expect
protection, care and love.
The individual and societal consequences of family violence can be severe:
Physical injury or death
Chronic health conditions: Research shows a correlations between domestic
violence and health conditions such as arthritis, chronic neck, back and
pelvic pain, migraine headaches and stomach ulcers.
Broken families, and the emotional devastation that occurs, both for
adults and children.
Increased health care expenditures: According to the Centers for Disease
Control and Prevention (CDC), the health-related costs of rape, physical
assault, stalking, and homicide by intimate partners exceed $5.8 billion
each year.
The physical consequences are bad enough.
Imagine for a moment what it is like emotionally to be the victim of family
violence. There is the terrible fear of physical intimidation that is sometimes
hard for those of us who are men to understand.
Think of what it must be like to be a 100-pound woman trying to run away from
the anger of her 200-pound husband. Or a 60-pound child feeling the terror of
being punished by a 130-pound, emotionally out-of-control mother. Or a disabled
elderly woman, unable to move quickly, being threatened by a grown son or
caregiver.
And then, there is the aspect of betrayal. It is natural to expect love and
caring from our family members and intimate partners.
So imagine the emotional as well as physical devastation that occurs when
someone you love, and who is supposed to love you, hits you, kicks you, punches
you, or shakes you. It’s horrifying. And because it occurs in the home, the
victim feels trapped, and unable to escape.
Why Does Family Violence Occur?
According to the Centers for Disease Control and Prevention (CDC), the common
element in every incident of intimate partner violence is the abuser’s need for
power and control in the relationship.
We talk a lot about ‘risk factors’ in the field of public health. For
example, an obese person has a greater risk of contracting cardiovascular
disease than a person of normal weight. Similarly, there are risk factors for
being either a perpetrator of, or victim of, family violence.
Mental illness is a risk factor. Evidence indicates that violent intimate
partners may be more likely to have personality disorders such as schizoidal/borderline
personality, and dependency and attachment problems.
Perpetrators are also more likely than their non-violent peers to be
depressed and have low self-esteem.
Alcohol and drug use or addiction is also a risk factor. Perpetrators of
family violence are often using alcohol or drugs when they lash out at their
victims.
There is also an intergenerational, or cyclical aspect to abuse.
If a child witnesses violence or experiences it in his or her family growing
up, he or she is more likely to perpetrate or become a victim of it as an adult.
Women who witness domestic violence as children may be at higher risk for
victimization in their own relationships.
The child who is abused becomes the teenager who is violent toward his peers,
and then the man who is violent toward his wife, or elderly parent. The cycle
keeps repeating itself unless it is broken.
Even now, societal norms reinforcing male dominance and violence as an
acceptable problem-solving strategy and means of control still exist in many
areas.
The notion that "domestic violence is a family or private matter" and not the
business of the state is now considered to be a myth in public health circles,
but for many years that is the way our law enforcement, criminal justice and
military communities saw it. It will take sustained effort to overcome that
mistaken perception where it still exists. Fortunately our law enforcement and
judicial systems have evolved to a ‘no tolerance’ attitude.
HHS Efforts to Address Family Violence
What can be done? There is great hope as we move forward on public health
strategies to fight family violence.
Many of our agencies have a piece of the fight: NIH, CDC, SAMHSA, HRSA,
Aging, the Administration on Children, Youth and Families, and the Office on
Women’s Health.
Our approach – focusing on aid to family violence victims, as well as
research and prevention – complements the good work of other organizations and
agencies.
At the most basic level, we must provide protection and immediate assistance
to victims of family violence. As Secretary Thompson has said, we must ensure
that people in dangerous situations and experiencing abuse, know that there is
help available and where to get it.
The National Domestic Violence Hotline, available 24 hours a day, 7 days a
week, in 139 languages, provides crisis intervention, referrals, counseling and
advocacy to victims of domestic violence.
We are committed to preventing family violence. Many of our strategies focus
on prevention strategies tailored toward victims – reducing their risks for
future violence and mitigating the consequences of exposure.
There is also a growing emphasis on strategies directed toward perpetrators
and potential perpetrators to break the cycle of family violence.
To give just a few examples of our many projects:
- CDC research is looking at how other health behaviors and violence
issues, such as substance abuse and dating violence, affect risk factors for
family violence.
- Victims of child maltreatment are at risk for other types of violence later
in life, including youth violence, suicide, and intimate partner violence. So
CDC is funding and evaluating a multi-level parenting program to prevent child
maltreatment by improving positive parenting skills.
- CDC is also studying how social networks – friends, relatives, and
acquaintances – can influence the behavior of both men and women in abusive
situations. Results from the study will help us direct prevention messages
to those people in the best position to assist women in leaving abusive
situations.
- HRSA trains primary providers in the treatment of family violence among
their client base.
- The National Institute of Mental Health continues to support research on
the consequences of trauma, including studies of post-traumatic stress
disorder (PTSD), which is a common outcome of domestic violence.
- The National Resource Center on Aging and Injury provides information to
caregivers, health care practitioners, policymakers, and others seeking
training and technical assistance in reducing injuries and abuse among older
Americans.
State and Community-based Efforts
Much of the good work to prevent and treat family violence is occurring at
the state and local level. At the federal level we are helping to fund and
support those efforts.
The Administration on Children, Youth and Families funds state-level
child abuse and neglect treatment and prevention programs, and also gives
grants to private sector organizations and researchers to identify the
causes and consequences of child abuse and neglect, and to recommend
solutions.
The Centers for Disease Control and Prevention has awarded nearly $4
million in the last two years to 14 state domestic violence coalitions to
develop and coordinate activities to prevent domestic violence.
SAMHSA is funding a project called the National Child Traumatic Stress
Initiative, establishing 18 local treatment and community service centers to
treat children who have experienced trauma, and collect clinical data.
Last fall, Mayor Bob Walkup of Tucson started an initiative called Tucson
Men Against Domestic Violence. This is an innovative approach, relying in
part on peer pressure to break the cycle of family violence. Men need to
tell men it’s unacceptable. We can tell our peers that family violence is
not a private matter, that it is not justifiable in any circumstances. We
can tell other men in no uncertain terms, "You’re wrong. No, she wasn’t
‘asking for it.’"
We need to take violence out of every punch line in every locker room. Even
in jest, this kind of talk diminishes the problem and deadens the concern we
should show. We can also call the police, if necessary, to diffuse a bad
situation. We can provide emotional and moral support to the women in our
lives whom we suspect are in an abusive relationship.
Conclusion
The public health approach of preventing and responding to family violence is
multi-faceted, and involves nearly all of the various agencies within HHS. Our
strategies compliment the way those of you in law enforcement, criminal justice,
child protective services, and advocacy groups approach the problem.
Partnership between public health and law enforcement is essential; each of
us has a unique perspective that can benefit the other. Like so many of our
seemingly intractable public health problems, eliminating family violence will
rely on behavioral change at the individual level. It’s not easy to change
behavior, but it is certainly possible. Look at what we’ve accomplished in the
past 30 years.
We changed the climate in America regarding cigarette smoking. We helped
convince people not to drink and drive. We educated the public about the
behaviors that lead to HIV and AIDS, and the ways to prevent the spread of these
diseases. While all of these problems still exist, we have made significant
progress fighting them.
As we move forward in all of our fields of expertise, we must devote
ourselves to the fundamental principle that all women, children and men have the
human right to be safe, especially in their own homes. As we move out from that
principle into public policy in our various disciplines, let’s not forget the
human face of family violence.
At a fundamental level it is a violation, a betrayal of the trust and love
that should occur within our families and intimate relationships. Family
violence is beneath us as individuals; it is beneath us as a nation.
And let’s not be too ‘clinical’ about this. Look around in your own lives. If
the one-in-four statistic is correct, chances are, someone you know, if not
several people, are being abused by family members or intimate partners.
Take the action needed to stop the cycle of abuse.
On behalf of the President, Secretary and the entire Department of Health and
Human Services, we look forward to working with each of you to eliminate this
scourge on family life, this betrayal of human dignity.
Thank you for your attention and I would be pleased to answer your questions.
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Last revised: January 9, 2007
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