Domestic abuse is a critical social and public health problem in the United States, affecting millions of individuals annually. This paper provides a broad overview of issues of domestic abuse in the United States by examining the research literature of heterosexual partner abuse (both male and female), elder abuse, and the intervention efforts by the American health care system in fighting this social epidemic.IntroductionDomestic abuse in the United States is a large-scale and complex social problem. The family is perhaps the most violent group, with the home being the most violent American institution or setting today (Lay, 1994). The majority of people who are murdered in the United States are not killed by a stranger during a hold-up or similar crime but are killed by someone they know 16 percent of the time by a family member (Mason, 1993). Not surprisingly, the Center for Disease Control and Prevention has identified interpersonal violence as a major public health problem (Kroll, 1993).Several studies that have attempted to establish the rates of domestic abuse among the U.S. population have been inconclusive. According to the FBI, some form of domestic violence occurs in half of the homes in the United States at least once a year (Dickstein, 1988).This paper will explore the diverse characteristics and underlying causes of partner and elder abuse. Through an examination of the research literature, the author will present a broad overview of current empirical trends and theoretical orientations that surround female and male partner abuse and abuse of the elderly while considering the role of health care in combating the problem.Historical Perspective of Domestic ViolenceHistorically, domestic violence has been a downplayed and, oftentimes, culturally condoned, American tradition. In the colonial period, laws derived from English common-law permitted a man to beat his wife when she acted in a manner that he believed to be inappropriate. For example, the so-called "Rule of Thumb" law, which permitted a husband to beat his wife with a stick that could be no larger than the circumference of his thumb, was in effect until the end of the nineteenth century (Dickstein, 1988).The issue of domestic violence, especially wife abuse, first gained national attention in 1974 with the publishing of Scream Quietly or the Neighbors Will Hear by Erin Pizzey, the founder of Chiswick s Women s Aid (a shelter home in England for battered women). Pizzey s work helped to stimulate feminist concern and outrage over wife beating, verbal abuse, financial restrictions, and social isolation of women by their husbands (Utech, 1994). Shortly thereafter, the women s liberation movement, through the National Organization for Women (NOW), advocated for the end of domestic violence against women and sought improved social services for battered wives. NOW also was actively engaged in promoting shelter homes and lobbying congressional leaders for legislation that would result in better treatment and protection of women s health and well-being (Utech, 1994). In 1978, sociologists Murray Straus, Suzanne Steinmetz, and Richard Gelles concluded in their comprehensive study of domestic violence that 3.8 percent of women in over 2000 American families had been subjected to one or more attacks by their husbands in the previous year (cited in Ross & Faustini, 1989). According to Strauss (1978), "violence is built into the very fabric of American society, and physical force is the ultimate resource on which most of us learn as children to rely if all else fails and the issue is crucial" (cited in Ross & Faustini, 1989, p.99). Although it was a highly held assumption in the 1950s and 1960s that violence occurred only in "minority" or "lower class" families, by the 1980s research documented the fact that violent conflict occurred at all socioeconomic levels of society and among all racial and ethnic categories (Bedard, 1992).An important factor to consider when studying domestic violence is the involvement of medical care. The medical profession was greatly affected by the advocacy of the women s liberation movement and has, in recent years, attempted to combat this social ill both by itself and in coordination with the legal and social service professions. For example, beginning in 1992, the Joint Commission on the Accreditation of Health Care Organizations, required that all accredited hospitals implement policies and procedures for identifying, treating, and referring victims of abuse (Mason, 1993). This included in-service training programs for staff members of their emergency departments and ambulatory care facilities (Mason, 1993). In 1994, 83 organizations, including the American Nurses Association and the American Bar Association, met to identify gaps and barriers between the health care delivery and criminal justice systems in dealing with family violence cases. Among their recommendations were the following: a mechanism for community professional coordination in assessment to maximize family safety; the creation of community-based family violence coordination councils; and the need to establish, in every community, a comprehensive, culturally sensitive, and accessible intervention system for family violence that links health, justice, mental health, social service, and educational systems (Stanley, 1994). In addition, the American Medical Association (AMA) has published guidelines for health care professionals to use in identifying domestic violence victims. While the social, medical, and judicial systems have worked together in order to fight domestic abuse, one important problem still exists. Research produced on domestic violence by one system tends to display inabilities in connecting with the research of the other systems.Theories on the Existence of Domestic AbuseA variety of sociological and psychological theories have been proposed in trying to understand the underlying nature of domestic abuse. Research on family abuse has, on a consistent basis, found that the phenomenon is associated with intergenerational transmission, low socioeconomic status, social and structural stress, social isolation, and personality problems or psychopathology (Gelles & Maynard, 1987).Theories on the causes of domestic abuse have focused on such factors as people s individual characteristics and life experiences, including the presence of problems such as social stress, alienation, unemployment, poverty, drug or alcohol abuse, past history of child abuse, personality disorders, and psychological problems (Yegidis, 1992). However, theories centered on these variables fail to explain why the majority of the population that does not experience domestic abuse, whether as a victim or a perpetrator, are not affected by these variables. Additionally, research has demonstrated the elimination of personal problems, such as the ones listed above, does not contribute to ending domestic abuse in a relationship (State of Iowa, 1994). Nevertheless, for the purpose of framing particular studies of domestic abuse, these theoretical approaches are still important. Due to each theory s shortcomings, it is important for researchers to adopt a theoretically holistic approach. The fact that each case of domestic abuse is somewhat different from another calls for using a variety of theoretical orientations to better examine the nature and extent of abuse itself. While domestic abuse can be studied through theoretical "lenses" that are either psychological or sociological in nature, it is important also to examine this issue from an interdisciplinary perspective.Modeling TheoryA particularly useful perspective in which to study abuse is modeling theory. Bandura (1977) proposed that learning is composed of both a modeling component and "reciprocal influence." The latter suggests that we can shape our futures by influencing our environments. In explaining how social learning theory accounts for family abuse, O Leary (1988) analyzed the effects of modeling on behavior, the role of stress, the use of alcohol, the presence of relationship dissatisfaction, and aggression as a personality style.Modeling involves the observation by the child of physical aggression by parents or the direct experience of having been physically abused. In a study of wife abuse and marital rape, it was found that viewing parental violence was equally important in creating a future pattern of abuse as the direct experience of child abuse itself (Yegidis, 1988). Modeling, therefore, increases the likelihood that one will use violence in order to handle interpersonal difficulties (Yegidis, 1992).Stress and AbuseExtensive literature exists on the relationship between stress, frustration, and aggression (Staub, 1971; Farrington, 1980). Stress alone does not cause violence, but it may be a stimulus that serves to arouse some individuals (Yegidis, 1992). As a result, an individual may choose a violent course of action after being exposed to a stressor and having been influenced by viewing parental aggression (Yegidis, 1992).Abusers generally tend to possess an aggressive personality style. Consequently, people possessing this trait are more likely to get angry than others and may actually get angrier more often than others (Yegidis, 1992).Abuse and AlcoholResearch suggests some important aspects to the relationship between family abuse and alcohol. From the perspective of the abuser, alcohol may not only lead to the violence, but provide an excuse for it (Martin, 1976). However, for the victim, alcohol use can lead to a numbing effect as well as feelings of powerlessness (Yegidis, 1992). Additionally, it is common for the abusive behavior of the perpetrator to be permitted and excused by the victim because the perpetrator was under the influence of alcohol (Yegidis, 1992).The "Cycle of Violence"Domestic abuse typically follows a cyclical pattern that gives an even stronger meaning to the term "cycle of violence." In 1979, Walker identified three phases in the cycle theory of violence: tension-building, acute battering, and honeymoon (Curnow, 1997). According to Walker:During phase one, the tension-building phase, the batterer becomes increasingly moody, hostile, and critical of [the] partner. Minor battering incidents may occur... During phase two, the acute battering incident, the [batterer] is likely to assault the [victim]... Major assault of the [victim], physically and psychologically, usually distinguishes the acute battering incident from the minor battering incidents that may occur during phase one... Shortly after the acute battering phase is the honeymoon phase. The batterer may apologize, beg forgiveness, or promise that [the] violent behavior will never happen again. (Walker, 1984 and Saunders-Robinson, 1991 as cited in Curnow, 1997, p.128).Sally Curnow (1997) examined female domestic abuse victims experiences within this cycle to discover when help seeking and reality behaviors (that is, behaviors resulting from the realization of the violent situation) were most likely to surface. The results revealed that periods of help seeking and reality behaviors do exist within the cycle, occurring in a period referred to as the "open window phase," which takes place after the acute battering phase and prior to the honeymoon phase (Curnow, 1997). These findings have significant implications for health services investigation in discovering the best ways to provide victim health services and attract victims to those services, proving that the cycle of violence can be broken.Domestic Violence Towards WomenAn estimated three to four million women annually in the United States are the victims of physical abuse by their intimate partners (Harris & Cook, 1994). In addition, violence is the second leading cause of injuries to women ages 15 through 44 years (Velsor-Friedrich, 1994).Incidences involving domestic abuse against women are often perceived by both the participants involved and by those outside the relationship in ways that involve blame (Harris & Cook, 1994). In a variation of the fundamental attribution error, aggressors will often attribute their abusive behavior to external causes (e.g., work-related stress or something the victim may have done to anger him), while victims attribute the abuse to internal factors within themselves or situational factors about the abuser (e.g., "It s only because he has been drinking") (Overholser & Moll, 1990). The frequent occurrence of victim self-blame is reinforced by social attitudes which are responsible for often blaming the woman for inciting the abuse or not leaving her abuser (Frieze, 1979; Walker, 1984).The Women s Health Aspect of AbuseWhether or not battered women are identified, they are commonly found in nearly every area of the health care system (Curnow, 1997). Battered women account for 21 percent of all women who use the emergency room (Dickstein, 1988). While these statistics are alarming, they do not fully reflect the problem because many victims do not report abuse and many health care professionals are not able to identify which of their patients are victims (Davison & Couns, 1997). Moreover, many patients are rarely asked about domestic violence since a large number of physicians and nurses have not been trained in methods to identify and help victims (Ambuel et al., 1996). Female domestic abuse victims can be very difficult to identify. According to Dutton and Painter (1981):...[T]hey may appear evasive and depressed. They may be reluctant to self-identify because of embarrassment and stigma. They fear being demeaned, not believed, or made to feel responsible for the attack. They are afraid of reprisals from the batterer if they disclose, and they feel skeptical that anything can be done by outsiders. (cited in Tilden, 1989, p.314)Victimized women see themselves as less than healthy (Garnett, 1994). Women who have been raped or physically assaulted see their primary health physician twice as much as women who have never been abused (Garnett, 1994). According to research supported by the National Institute of Health s Office of Research on Women s Health, victimized women were 2.5 times more costly to the health care system than women who had never been victims of abuse and the year following the year of an attack is when most abused women begin to increase their use of medical services (Garnett, 1994).Additionally, abuse of pregnant women is not a rare occurrence. The National Institute of Health (NIH) reports that 45 percent of battered women are abused during pregnancy (Garnett, 1994). The consequences of the abuse of pregnant women are alarming. Physical or sexual assault involving abdominal trauma can lead to abruptio placentae, a condition characterized by the premature separation of the placenta from the uterus wall that can result in fetal loss or early onset of labor and the delivery of a live, low-birth-weight or pre-term infant (Newberger, Barkan, Lieberman, McCormick, Yllo, Gary, & Schechter, 1992). Additional consequences of abdominal trauma during pregnancy include fetal fractures; rupture of the mother s uterus, liver, or spleen; pelvic fractures; antepartum hemorrhage; uterine contractions; premature rupture of membranes; and infection that can lead to the early onset of labor and possible fetal loss (Newberger et al., 1992). Furthermore, victimizationof a woman can result in the exacerbation of chronic illnesses such as hypertension, diabetes, or asthma which may have jeopardizing effects on the fetus (Newberger et al., 1992).Why Do Women Stay?There are numerous answers to the commonly asked question of why a woman would stay in an abusive relationship. For many women, no sources of financial support or housing exist. Therefore, why should abused women leave their homes to seek refuge in community shelters (if and when room is available) or to live on the streets? Additionally, the responsibility of childcare further complicates the problem (Bundow, 1994).Another serious reason concerns the fear of retribution by the abuser. A batterer may threaten to further, and more severely, abuse the victim if she tries to seek help (Pagelow, 1981). Despite the abuse, a woman may still love her partner and, consequently, may feel guilty for even thinking about leaving (Pagelow, 1981). Many victims possess low self-esteem and humiliation caused by repeated abuse (both physical and emotional) and embarrassment or shame may be sufficient reason for the victim to stay (Schiavone & Salber, 1994). Due to difficulty in accepting that they are being abused, victims may continue to deny the dire need to make changes in their home lives, even if their abuser goes to jail for a night (Meoli, 1994).Domestic Violence Against MenMany Americans react with disbelief after hearing about the topic of abused men. Abused husbands are a frequent topic for jokes (as in the cartoon image of the husband being chased by his wife who is waving a frying pan). Saenger (1963) found that in 73 percent of the depictions of domestic violence in newspaper comics, it was wives, not husbands, who were the perpetrators.Straus, Gelles, and Steinmetz (1980) conducted a nationally representative study of family violence and discovered that the total violence scores appeared roughly even between husbands and wives. In addition, they found that wives tended to be more abusive in all categories except pushing and shoving. Straus and Gelles (1986) did a follow-up survey and compared their data to a 1975 study. They found that in the 1970s, domestic violence against men rose from 11.6 to 12.1 percent. More recently, at the 13th World Congress of Sociology (1994), it was reported that for the US in 1992, for the average number of reports of abuse by males and females, husband on wife severe assault occurred at a rate of 2 percent (that is, 20 instances of severe husband on wife assault for every 1000 couples), while wife on husband severe assault occurred at a rate of 4.6 percent (cited in Garrod, 1995). In addition, husband on wife minor assault was reported to occur at a rate of 9.9 percent, whereas wife on husband assault occurred at a rate of 9.5 percent.Underlying CausesFamily abuse is directly linked to status in the family and socialization ("Attributes of abused men," 1994). Even though they must often physically enforce their "right" to exercise the role as master of the home, men are culturally prepared for this role and are socialized to be dominant and women to be subordinate ("Attributes of abused men," 1994). However, this does not mean that women can't be abusive. A person who is punched, kicked, or cursed at will usually respond with some form of physical defense. Female violence toward male partners that is neither in response to being battered nor expressed through self-defense can be very dangerous ("Attributes of abused men," 1994).There are many serious effects of society s reluctance to consider the potential for domestic abuse by females. In our society, a large number of girls are told to slap a boy if he gets "fresh" (Brott, 1994). Movies and television programs display scenes of women punching and/or slapping men with complete impunity, while the viewer usually reacts with support for the women s character (Brott, 1994). While a slap is usually a harmless act, it is important to consider that a slap is still violent act.When considering the perceived responsibilities of the victim, Harris and Cook (1994) found that the battered husband was held least responsible. This result was especially strong when the battered husband had verbally provoked his wife.A common question exists when examining domestic abuse against men: If men are usually bigger and stronger than women, then why don t they try to protect themselves? To answer this question, we must examine the issue from a child development standpoint. At the same time that girls are being taught that it is acceptable to slap a boy, boys are being told to never hit a girl (Brott, 1994).The number of cases and the severity and pattern of the violence used against the victims are the major factors differentiating men s violence against women from the violence of women against men. The civil protection order and the criminal court process are effective tools for protecting almost all heterosexual male victims because women rarely attempt "separation violence," the violence that results as the victim attempts to leave the abuser ("Attributes of abused men," 1994).

Why Do They Stay?Although they may not be victimized if they leave their spouse, there are many reasons why abused men stay in their violent homes. Abused men, like abused women, fear that if they leave their spouse, the abuse that they have encountered may be directed against their children (Brott, 1994). Additionally, many men are hesitant to leave because women get physical custody of children in a large majority of divorce cases and they may also fear that the courts will limit children visitation and access (Brott, 1994).Deciding to leave an abusive relationship is just one part of the problem for an abused male. Another part is choosing where to go because very few shelters exist for them to find refuge (Brott, 1994). A variety of programs exist to help abusive men control their violence more effectively, however, finding comparable programs that exists for violent women is an extreme challenge (Brott, 1994). Potentially, groups and agencies that assist abused women could also extend their services to aid battered men.Elder AbuseThe first case reports of elder abuse began appearing in the literature only 20 years ago (Lachs & Pillemer, 1995). Elder abuse is a seldom reported category of domestic abuse, but is nevertheless on the increase (Garnett, 1994). As the members of the baby boomer generation advance in their years, senior citizens will account for an estimated 20 percent of the US population by the year 2030 (U. S. Bureau of the Census, 1986). Advances in medical technology increasing the life expectancy for larger proportions of individuals are being regarded as the main factor behind this increase. It has been estimated that 4.7 million senior citizens in America require assistance with their personal care (Pillemer & Finkelhor, 1989). This statistic, along with the current movement toward de-institutionalization and care at home, has forced the elderly to become more dependent on their families for meeting their daily needs.According to research by Pillemer and Finkelhor (1989), the caregiving spouse is more likely than the adult children to inflict abuse upon the dependent older person.Elder abuse can manifest itself in many forms. These include:physical abuse physical neglect ignoring their nutrition and other basic needs psychosocial abuse, which includes social neglect and isolation exploitation violation of rights self-neglect, in which the victim gives up on himself or herself (Garnett, 1994). Victims of elder abuse are most likely to be female. A 1991 study found that 68 percent of the cases of elder abuse were women and approximately 71 percent of abuse occurred to victims over the age of 70 (cited in Garnett, 1994).Neglect is responsible for a large amount of the controversy concerning the definition of elder abuse (Lachs & Pillemer, 1995). Cases of neglect of the elderly frequently generate questions about who is the responsible caretaker, what the caretaker s exact responsibilities are to the neglected person, and whether the neglect itself was intentional (Lachs & Pillemer, 1995). Attempts to divide elder abuse into subtypes (to incorporate physical violence, psychological or emotional abuse, marital exploitation and/or the misappropriation of money or property, and neglect) have been criticized as an academic exercise that ignores the needs of the victim (Lachs & Pillemer, 1995). The final result of neglect is the inability of an older adult to function in the community, thus initial interventions should be aimed at improving the quality of life first with the assigning of blame being secondary in importance (Lachs & Pillemer, 1995). Because of this reason, many authorities prefer to avoid the terms "abuse" and "neglect" instead opting to label the problem as "inadequate care of the elderly," which includes acts of both omission and commission (Fulmer & O Malley, 1987; Johnson, 1991).Theories Behind Elder AbuseThe theoretical explanation of elder abuse is a debated topic in the literature. Five social psychological theories play an important role in understanding elder abuse and why it occurs: role theory, exchange theory, family systems theory, environmental theory, and transgenerational violence theory.Role theory emphasizes that severe strains can be placed upon the relationship when adult children care for their parents (Lay, 1994). When the child adopts the parent role and the parent slowly assumes a child-like dependency, role reversal occurs, thereby contributing to psychological problems for both generations (and affecting the way the aged parents are treated) (Butler & Lewis, 1973; Gresham, 1976). The existence of role conflict is believed to significantly increase the potential for abuse (Lay, 1994).Supporters of exchange theory believe that if some gain exists for the abuser, then maltreatment will occur (Fulmer, 1989). This gain emanates from psychological, emotional, and financial enhancement (Lay, 1994). Maltreatment of aged parents by their children may be inflicted for the sake of revenge possibly attributed to perceived, or even actual, mistreatment during childhood (Lay, 1994). This is likely to occur among individuals who lack self-esteem and control in other relationships (Lay, 1994).Family systems theory accurately explains passive forms of elder abuse such as neglect by viewing the family as a holistic unit where each member has attachments to each other and to previous generations (Beck & Ferguson, 1981; Lay, 1994). Each family member possesses behavior patterns and varying degrees of differentiation that set each member apart from the other (Lay, 1994). Differentiation is believed to coincide with emotional and intellectual maturity and is often associated with increased responsibilities within the family itself (Lay, 1994). Low differentiation individuals tend to be less adaptable, which results in emotional rather than intellectual responses to stressful situations (Miller & Winstead-Fry, 1982). These individuals have a greater chance of reacting violently when placed in the role of the caregiver (Lay, 1994). Another proposed concept of elder abuse categorized within the family systems theory is that caregiving family members, in order to maintain a functional family unit, will deny the elder individual s health care problems (Lay, 1994). This theory s hypothesis is that family survival is dependent upon maintaining the false idea of the elder person s immortality and invincibility (Lay, 1994).Environmental theory supports the belief that the abuser s environment and personal traits are essential ingredients of violent behavior (Bottom & Lancaster, 1981). Research has revealed that people who abuse the elderly have been exposed to violence before or have been childhood victims of violence (Bottom & Lancaster, 1981). Additionally, similar to exchange theory, people with limited self-control are more likely to use violence to rid themselves of pent-up hostilities (Lay, 1994).The orientation of the transgenerational violence theory, deriving ideas from environmental theory, is centered on the belief that violence is learned behavior (Lay, 1994). Individuals raised in environments where abusive behavior is condoned will essentially learn that abusive behavior is a normal method for resolving conflict. As these individuals mature, they will also resort to using abusive behavior in coping with conflict.Similar to female spouse abuse, studies show that elder abuse does not result from the increasing needs of the victim but rather from the deviance and dependence of the abusers (Pillemer & Finkelhor, 1989). In their study on causes of elder abuse, Pillemer and Finkelhor (1989) found that elder disability may play a role in cases where adult children inflict the abuse, however, this is considered small compared to that of abuser deviance. In cases where the elderly are abused by their spouses, their findings show that somewhat dependent victims appear to be involved, but the dependence may be a function of high conflict situations in which the victim is demeaned and kept in a role that is inferior.The Health Care System as an Intervention PointAs changes take place in the manner by which health care is delivered, health service researchers have begun to examine ways of reaching out to individuals who require special attention or care, yet are unable to obtain it. This approach has also been applied to domestic abuse victim health services. With the number of injuries that domestic abuse causes annually, the health care system has begun to see itself as an important link in helping the victims. The health care profession is in a position to identify abused victims, administer the proper care they require, and refer them to necessary social services. Unfortunately, numerous articles report many health care professionals do not perform these services for battered women, especially in the emergency room (Curnow, 1997; Gerbert, Johnston, Caspers, Bleecker, Woods, & Rosenbaum, 1996; Saunders, Hamberger, & Hovey, 1993; Dickstein, 1988; Tilden & Shepard, 1987; McLeer & Anwar, 1987).In research on domestic abuse among emergency room patients, Goldberg and Tomlavich (1984) discovered an inverse relationship between victim behaviors and beliefs. For example, even when they reported that the violence in their relationship was decreasing or had ceased, victims requested specialty services on the survey (i.e. counseling). In addition, victims requested pain medication more often than any other type of medical service (Goldberg & Tomlavich, 1984).Studies by Drake (1982) and Lichtenstein (1981) found that female victims who had been battered were more likely to hold negative opinions of the emotional care that they received from health providers (in Tilden & Shepard, 1987). They were especially critical of impersonal and insensitive treatment (Tilden & Shepard, 1987). In studies of hospital emergency departments, Goldberg and Carey (1982) and Rounsaville (1978) concluded that medical professionals often lack knowledge about domestic abuse and may be influenced by stereotypes and prejudices (Tilden & Shepard, 1987). In a study of four urban emergency departments, Kurz reported that in only 11 percent of the cases of probable battering, staff responded therapeutically (meaning with concern for the woman as an individual, with sensitive interviewing, careful chart documentation, and with referral to resources) (Tilden, 1989). Further compounding this problem is the fact that when women seek medical help and are greeted by negative responses, their feelings of helplessness are increased (Hendricks-Matthews in Curnow, 1997). In addition, Hayden and colleagues (1997) found that more than one-third of female domestic abuse victims do not disclose their victimization if they know that health care providers are required by law to report such incidents.Using ethnographic techniques, Sugg and Inui (1992) concluded that physicians who explored for domestic abuse in the health care setting felt the procedure to be similar to "opening Pandora s box" in fact, 18 percent of the physicians interviewed used that actual phrase. The physicians participating in this study (the majority of whom were family practice specialists) reported such problems as lack of comfort in dealing with the issue, fear of offending the patient, a sense of powerlessness, loss of control, and time constraints--all of which constitute barriers to domestic abuse recognition and intervention in cases of domestic abuse seen in the primary care setting (Sugg & Inui, 1992).Gerbert and colleagues (1996) investigated how female victims of domestic abuse were treated in health care settings. The researchers identified three levels of barriers encountered by female victims: patient, provider, and organizational. On the patient level, many of the women interviewed chose to conceal their abuse from their health care provider due to shame or fear of retaliation from their partner. At the provider level, the patients believed that health care providers were apathetic regarding their problems. On the organizational level, some women felt that the health care system did not assist health care providers in handling domestic abuse beyond treating the immediate injuries (Gerbert et al., 1996).Analyzing research that investigates health professionals perspectives of domestic abuse helps to confirm the startling reality that exists for victims seeking assistance. As severe a health threat domestic abuse poses, many victims have been, or are currently, misidentified or met with apathy by health care professionals. This phenomenon is due to many factors, the most common of which include inadequate training (many training programs do not even discuss domestic abuse) and tendencies toward feelings of "victim blaming." Many health care professionals adopt the stance that domestic abuse is a problem that falls outside the spectrum of their job description. These professionals view the ideology of the family as a private domain and believe difficulties inside the home can and should be settled by the family members themselves (Davison & Couns, 1997).Assessment of AbuseThe detection of abuse requires a high degree of suspicion during the assessment of the patient. Physicians fail to always recognize and/or acknowledge the source of repeated injuries. One study found that 35 percent of female emergency room patients are treated for symptoms related to ongoing abuse, but only approximately 5 percent of the women are identified as victims of domestic abuse (Bowers, 1994). In 1992, the American Medical Association (AMA) published Treatment Guidelines on Domestic Violence. In addition to the physical assessment, suggestions for the physician to follow in the interview of the victim are mentioned as well. These include:Physicians must ask direct, specific questions to determine the occurrence or extent of abuse since many women do not recognize that they are battered. The fact that a medical encounter may provide the only opportunity to stop the violence before more serious injuries occurs. Considering the possibility of assault when a victim s explanation of an injury does not seem plausible, or when the victim has delayed medical treatment. [The] patient may appear frightened or nervous or exhibit stress-related symptoms in addition to physical injury Maintaining a complete and detailed description of the event, in the victim s own words if possible and of resulting injuries, including photographs if applicable. Being aware that the severity of current or past injury is not an accurate predictor of future violence. The patient s safety should be discussed before leaving the physician s office or treatment center. Being aware of local resources to make appropriate referrals. A physician who treats a victim and does not inquire about domestic abuse or accepts an unlikely explanation for the injury could be held liable if the victim returns to the abuser and is injured again. (American Medical Association, 1992) Determining if Elder Abuse Exists and Elder Abuse Community ResourcesThe question of when to assess an elderly person for possible abuse is difficult to answer. Guidelines by the AMA recommend that all elderly adults be asked by their physicians about family abuse, even when symptoms that are potentially attributable to abuse or neglect are not present (American Medical Association, 1992).Many health care professionals are often unaware of the resources that exist within a community or how to access these resources (Lachs & Pillemer, 1995). The assistance of the Adult Protective Services (whether in providing a visit to the patient s home or in providing other services) is used when suspected abuse is reported (either due to legislative requirements or through voluntary action) by health providers to the state authorities (Lachs & Pillemer, 1995).Geriatric assessment clinics are available in some areas and conduct multidisciplinary evaluations that emphasize both the patient and the caregiver (Lachs & Pillemer, 1995). When used effectively, these clinics provide remedial interventions that can be well underway during an evaluation, since taking measures to improve the quality of life for the elderly person only requires that unmet needs be recognized and properly addressed (Lachs & Pillemer, 1995). Consequently, there exists no immediate need for definitive diagnosis or the assignment of blame (Lachs & Pillemer, 1995).The Role of Emergency Medical Services (EMS)Whether as an attempt to just escape the dangerous environment or because legitimate medical assistance is required, a domestic assault victim will often place a call for an ambulance. Emergency Medical Service personnel are a unique branch of the health care system in combating domestic abuse due to the fact that they have the opportunity to personally see the homelife in which the victim is immersed and therefore can greatly shorten the time that a victim can receive both early medical care (through prehospital medical intervention) and social service assistance (by contacting the appropriate agencies and/or referral services) (Schiavone & Salber, 1994).In the state of New York, the Suffolk County Task Force on Domestic Violence and the Division of Emergency Medical Services have joined forces to implement policies for the recognition and treatment of domestic violence (Schiavone & Salber, 1994). EMS responders in the area, in attempting to determine the chances of domestic violence, are required to conduct a subjective assessment on all victims of trauma (except for patients whose nature of injury is obviously not abuse-related) and in cases of illness where the level of suspicion is high. The latter can be difficult in assessing, but may include ailments that result in numerous 911 calls for help (such as in the case of "frequent flyer" patients) or inappropriate signs, symptoms, and time frames (Schiavone and Salber, 1994).More Than Just BandagesAside from medical and psychiatric treatment for injuries, potential victims of abuse can be given information and counseling from the health care provider in order to prevent future victimization episodes (and get out of the abusive environment) ("Guide to Clinical Preventive Screening," 1995). Psychological counseling, administered by either the primary care provider or a mental health professional, may assist the patient in ending personal relationships with abusive individuals ("Guide to Clinical Preventive Screening," 1995). Additionally, the patient can be provided with telephone numbers and encouraged to contact existing community resources such as crisis centers, shelters, protective service agencies, or the police department (if there is fear of injury) ("Guide to Clinical Preventive Screening," 1995).The health care provider may also identify individuals who are at a high risk of committing intentional injuries in the future ("Guide to Clinical Preventive Screening," 1995) . These individuals may be referred for counseling or family therapy in order to learn nonviolent alternatives to conflict resolution and stress management ("Guide to Clinical Preventive Screening," 1995). Lastly, the provider can report suspected cases of abuse and neglect to the appropriate social service and legal authorities. Unfortunately, the effectiveness of these measures is largely unstudied, and inadequate evidence exists to determine whether or not any of these strategies are successful in preventing violent injury in the future ("Guide to Clinical Preventive Screening", 1995).ConclusionDomestic abuse is an incredibly complex social phenomenon. Although it remains a social epidemic, increased attention through research and intervention efforts has helped to greatly combat this social problem through understanding its underlying causes.With the large amount of abuse victims that seek medical care annually, the medical profession is situated at an important location for identifying victims and referring them to the necessary (and available) social services, thereby helping to reduce the prevalence of victimization. However, intervention through the medical field, while assisting many victims, will not reach everyone affected by domestic violence. Other avenues of intervention also need to be further explored and/or improved in order to help those that refuse using health services because they fear being identified, lack injuries severe enough in nature to warrant medical care, or deny that they need medical assistance for abuse-related injuries.