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Often we think of domestic violence as a personal or marital problem. Those who know that a quarter to half of women around the world have suffered violence from an intimate partner are likely to associate domestic violence with gender issues. But how often do we think of domestic violence as a major health issue?

To understand why domestic violence is a health issue, we must look at the health consequences of domestic violence on its victims. The U.S. Department of Justice reported that 37% of all women who sought care in hospital emergency rooms for violence-related injuries were injured by a current or former spouse, boyfriend or girlfriend. Also, Domestic violence is repetitive in nature: about 1 in 5 women victimized by their spouse or ex-spouse reported that they had been a victim of a series of at least 3 assaults in the last 6 months. Furthermore, The level of injury resulting from domestic violence is severe: of 218 women presenting at a metropolitan emergency department with injuries due to domestic violence, 28% required hospital admission, 13% required major medical treatment, and 40% had previously required medical care for abuse.

In addition to injuries sustained during violent episodes, physical and psychological abuse are linked to a number of adverse physical health effects including arthritis, chronic neck or back pain, migraine and other frequent headaches, stammering, problems seeing, sexually transmitted infections, chronic pelvic pain, stomach ulcers, spastic colon, and frequent indigestion, diarrhea, or constipation. Fifty-six percent of women who experience any partner violence are diagnosed with a psychiatric disorder. Twenty-nine percent of all women who attempt suicide were battered; 37% of battered women have symptoms of depression; 46% have symptoms of anxiety disorder; and 45% experience post-traumatic stress disorder.

Domestic violence also shows severe consequences on children's health. Children who witness domestic violence are more likely to exhibit behavioral and physical health problems including depression, anxiety, and violence towards peers. They are also more likely to attempt suicide, abuse drugs and alcohol, run away from home, engage in teenage prostitution, and commit sexual assault crimes. In addition, each year, at least six percent of all pregnant women, about 240,000 pregnant women, in this country are battered by the men in their lives. Complications of pregnancy, including low weight gain, anemia, infections, and first and second trimester bleeding are significantly higher for abused women. Poor maternal health during pregnancy and lactating periods due to domestic violence may have consequences on the health of the child.

Another way to understand why domestic violence is a health issue is to look at the medical cost associated with domestic violence. A study conducted at Rush Medical Center in Chicago found that the average charge for medical services provided to abused women, children and older people was $1,633 per person per year. This would amount to a national annual cost of $857.3 million. A study conducted at a large health plan in Minneapolis and St. Paul, Minnesota, in 1994, found that an annual difference of $1775.00 more was spent on abused women who utilized hospital services than on a random sample of general enrollees. The study concluded that early identification and treatment of victims and potential victims will most likely benefit health care systems in the long run.

Thus, domestic violence is a health care issue. It has an immense impact on the health care system. Homicide and injury, mental illness, substance abuse and repetition of violence across generations indicate the range of health problems related to domestic violence. Because most women visit a health care provider for routine or emergency care, health care providers are often in the best position to help victims escape abuse. In four different studies of survivors of abuse, 70% to 81% of the patients studied reported that they would like their healthcare providers to ask them privately about intimate partner violence. Recent clinical studies have proven the effectiveness of a 2-minute screening for early detection of abuse of pregnant women. As the single most important, and most accessed institution in the lives of women, the health care setting can provide a unique opportunity to intervene, making it one of the newest and most critical areas of the domestic violence movement today.

Family Violence Prevention Fund (FVPF) has undertaken a National Health Initiative on Domestic Violence which has been improving the health care response to domestic violence nationwide. In 1995, the FVPF pilot-tested a training program in twelve hospitals in California and Pennsylvania. Projects of this initiative include the development of a highly popular resource manual, Improving the Health Care Response to Domestic Violence, and training for doctors. The next step was to develop multi-disciplinary clinical guidelines on domestic violence; confront society's acceptance of domestic violence and raise awareness by generating small and large scale public health campaigns to educate managed care companies, health policy makers, and administrators. This was tried out in 10 states. Now a National Health Resource Center on Domestic Violence (HRC) has been established. The HRC acts as the nation's clearinghouse for information on the health care response to domestic violence and provides free technical assistance and materials to thousands of health care providers each year through it's toll-free line: 888-Rx-ABUSE and by e-mail: health@fvpf.org. The HRC is one of five specialized resource centers in the country funded by the U.S. Department of Health and Human Services.

About two or three years ago, I noticed for the first time, a question about domestic violence in a routine medical history questionaire my obstetrician used for his patients during annual exams. I also noticed posters and fliers in the rest room used by women to collect urine samples. As a domestic violence victims' advocate, I was very happy to see this change and I commended my doctor for taking such preventive measures. He told me that he had been surprised to find the large number of patients responding positively to the new question. This year, as part of the Domestic Violence Awareness Month activities in October, SafePlace (Travis County Domestic Violence and Sexual Assault Survival Center) staff and volunteers distributed health care response packets to several Austin area doctors. Wouldn't it be nice if every primary care physician used such tools for early detection and prevention of this epidemic?

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