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.


    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.


    Last revised: January 9, 2007