Interpersonal violence is endemic in the United States. There has been growing public awareness through the media, community advocacy groups, and education in the schools to address this family-based problem. Inextricably tied to social, economic, cultural, and behavioral factors, interpersonal violence requires a multidisciplinary approach by the physician that addresses prevention, detection, intervention, and resolution.

Family physicians must maintain a high index of suspicion for interpersonal violence in their patient populations. Subtle presentations in patient behavior are often difficult to detect, and cultural and social factors may limit the manner and nature of presentation to the physician. Although challenges and opportunities for prevention and intervention are available on a societal level, the family physician is in a unique position to make a meaningful impact before violence escalates.

Interpersonal violence encompasses a wide variety of circumstances. These include:

• Emotional/psychological abuse.
  
• Financial abuse.
  
• Neglect (of dependent person).
  
• Physical violence.
  
• Sexual violence.
  
• Stalking, bullying, or internet aggression.
  
• Homicide.

These manifestations can be further characterized by the status of the individual vulnerable to such acts. Those at greatest risk include children, the elderly, pregnant women, persons who are physically or mentally challenged, immigrants, and members of racial or cultural minorities.

Emotional/psychological abuse includes humiliation, controlling behavior, repeated verbal assaults (name-calling), isolation (rejection, withholding attention and affection), threats, and public harassment, all of which can produce psychological trauma that reduces a person’s self-worth, value, and sense of efficacy. Emotional/psychological violence often coexists with chronic physical or sexual violence, but can also stand alone.

Financial abuse is when a person withholds resources such as money or transportation, or limits freedom of movement or association (eg, domination, isolation) of another person—a tactic often found in abusive relationships. Financial abuse most often involves the inappropriate transfer or use of an elder’s funds for the caregiver’s purposes.

Neglect is the chronic failure of a person who is responsible for the physical and emotional needs of another person to provide for those needs. This form of abuse most often occurs in family relationships and is directed at children, elders, or disabled family members. However, caregivers in other social/community settings, including child and adult day care, schools, group homes, nursing facilities, and hospitals, may be involved in neglect of a dependent person.

Physical violence, as defined by the Centers for Disease Control and Prevention (CDC), is the “intentional use of physical force with the potential for causing death, disability, injury, or harm.” This includes, but is not limited to, the following acts: scratching, pushing, shoving, throwing, grabbing, biting, choking, shaking, slapping, punching, burning, use of a weapon, and use of restraints or one’s body, size, or strength against another person. In the most extreme cases, physical violence may involve homicide.

Sexual violence, according to the CDC, is defined as “any sexual act that is perpetrated against someone’s will. Sexual violence may include a completed nonconsensual sex act (ie, rape), an attempted nonconsensual sex act, abusive sexual contact (ie, unwanted touching), and noncontact sexual abuse (eg, threatened sexual violence, exhibitionism, verbal sexual harassment). It includes the following four types:

• “A completed sex act is defined as contact between the penis and the vulva or the penis and the anus involving penetration, however slight; contact between the mouth and penis, vulva, or anus; or penetration of the anal or genital opening of another person by a hand, finger, or other object.”
  
• “An attempted (but not completed) sex act.”
  
• “Abusive sexual contact is defined as intentional touching, either directly or through the clothing, of the genitalia, anus, groin, breast, inner thigh, or buttocks of any person without his or her consent, or of a person who is unable to consent or refuse.”
  
• “Noncontact sexual abuse does not include physical contact of a sexual nature between the perpetrator and the victim. It includes acts such as voyeurism; intentional exposure of an individual to exhibitionism; unwanted exposure to pornography; verbal or behavioral sexual harassment; threats of sexual violence to accomplish some other end; or taking nude photographs of a sexual nature of another person without his or her consent or knowledge, or of a person who is unable to consent or refuse.”

Stalking, bullying, or internet aggression may take the form of harassment, threats, or physical violence that can lead to emotional or physical injury, and in some cases death. In its definition for stalking, CDC includes acts such as repeatedly following a person, appearing at a person’s home or place of business, making harassing phone calls or leaving objects or written, text, or internet messages, or vandalizing a person’s property. In addition to these acts, bullying can include spreading rumors, teasing, social isolation, and influencing others to “gang up” on someone in person or through aggression on the internet.

Web Site

Numerous studies have revealed disturbing evidence about the magnitude of interpersonal violence in the US society as well as opportunities for intervention. An estimated 25% of women and 7.9% of men are victimized at some point in their lives by a former spouse, cohabiting partner, or date. In one survey, 7.7% of women and 0.3% of men reported having been raped, and 22.1% of women and 7.4% of men had been physically assaulted. A typical respondent male victim averaged 4.4 physical assaults while women averaged 6.9 physical assaults. Thus, repeat victimization offers an opportunity for physicians to identify and intervene with persons at risk.

The annual incidence of all interpersonal violence has been estimated at 47 assaults per 1000 women and 32 assaults per 1000 men. Other estimates suggest that as a result of the 1.3 million women and 800,000 men who are physically abused in the United States each year, there are over 2 million injuries and 1300 deaths. Of particular concern is the finding that persons living in homes in which violent acts occur are more than four times as likely to be involved in additional violent acts than are those living in homes that are violence free.

Children, pregnant women, and the elderly are particularly vulnerable groups. Each year approximately 800,000 children in the United States are identified as victims of family violence or neglect. Half of homeless women and children report fleeing domestic violence. Pregnant women are at a greater risk of suffering physical abuse. It is a sobering fact that homicide is the leading cause of maternal death in the United States, and each year between 1,500 and 1,800 children die from abuse or neglect. Additionally, more than 500,000 elders are abused or neglected in domestic settings each year.

In mixed-sex domestic violence, the female partner is 30% more likely to be killed than the male partner, and most of these murders are committed with firearms. Although 28% of female homicide victims were killed by their current or former male partners, only 3% of men were murdered by current or former female partners.

African American, American Indian, and Alaska Native women and men report higher rates of domestic violence than the population as a whole, but socioeconomic factors confound the interpretation of such data. African Americans have a spousal homicide rate 8.4 times that of whites, whereas partners in interracial marriages have similar rates.

Other studies indicate a higher number of unreported incidents of physical and sexual abuse. More difficult to measure is emotional/psychological abuse or neglect, which is often insidious and difficult to detect.