Preamble

1. Recalling the World Medical Association Declaration of Hong Kong on the Abuse of the Elderly and the World Medical Association Statement on Child Abuse and Neglect, and profoundly concerned with violence as a public health issue, the World Medical Association calls upon National Medical Associations to intensify and broaden their efforts to address the universal problem of family violence.
   
2. Family violence is a term applied to physical and/or emotional mistreatment of a person by someone in an intimate relationship with the victim. The term includes domestic violence (sometimes referred to as partner, spouse, or wife battering), child physical abuse and neglect, child sexual abuse, maltreatment of older people, and many cases of sexual assault. Family violence can be found in every country in the world, cutting across gender and all racial, ethnic, religious and socio-economic lines. Although case definitions vary from culture to culture, family violence represents a major public health problem by virtue of the many deaths, injuries, and adverse psychological consequences that it causes. The physical and emotional harm may represent chronic or even lifetime disabilities for many victims. Family violence is associated with increased risk of depression, anxiety, substance abuse, and self-injurious behaviour, including suicide. Victims often become perpetrators or become involved in violent relationships later on. Although the focus of this document is the welfare of the victim, the needs of the perpetrator should not be overlooked.

Position

3. There is a growing awareness of the need to think about and take action against family violence in a unified way, rather than focusing on the particular type of victim or community affected. In many families where partner battering occurs, for example, there may be abuse of children and/or of older people as well, often carried out by a single perpetrator. In addition, there is substantial evidence that children who are victimized or who witness violence against others in the family are later at increased risk as adolescents or adults of being re-victimized and/or becoming perpetrators of violence themselves. Finally, more recent data suggest that victims of family violence are more likely to become perpetrators of violence against non-intimates as well. All of this suggests that each instance of family violence may have implications not only for further family violence, but also for the broader spread of violence throughout a society.
   
4. Although the causes of family violence are complex, a number of contributing factors are known. These includes poverty, unemployment, other exogenous stresses, attitudes of acceptance of violence for dispute resolution, substance abuse (particularly alcohol), rigid gender roles, poor parenting skills, ambiguous family roles, unrealistic expectations of other family members, interpersonal conflicts within the family, actual or perceived physical or psychological vulnerability of victims by perpetrators, perpetrator pre-occupation with power and control, and familial social isolation, among others.
   
5. Physicians have important roles to play in the prevention and treatment of family violence. Of course they will manage injuries, illnesses, and psychiatric problems deriving from the abuse. The therapeutic relationships physicians have with patients may allow victims to confide in them about current or past victimization. Physicians should inquire about violence routinely, as well as when they see particular clinical presentations that may be associated with abuse. They can help patients to find methods of achieving safety and access to community resources that will allow protection and/or intervention in the abusive relationship. They can educate patients about the progression and adverse consequences of family violence, stress management, availability of relevant mental health treatment, and parenting skills as ways of preventing the violence before it occurs. Finally, physicians as citizens and as community leaders and medical experts can become involved in local and national activities designed to decrease family violence.

Recommendations

6. The World Medical Association recommends that National Medical Associations adopt the following guidelines for physicians:
   1. All physicians should receive adequate training in the medical, sociological, psychological and preventive aspects of all types of family violence. This would include medical school training in the general principles, specialty-specific information during postgraduate training, and continuing medical education about family violence. Trainees must receive adequate instruction in the role of gender, power and other issues of family dynamics in contributing to family violence.
      
   2. Physicians should know how to take an appropriate and culturally sensitive history of current and past victimization.
      
   3. Physicians should routinely consider and be sensitive to signs indicating the need for further evaluations about current or past victimization as part of their general health screen or in response to suggestive clinical findings.
      
   4. Physicians should be encouraged to provide pocket cards, booklets, videotapes, and/or other educational materials in reception rooms and emergency departments to offer patients general information about family violence as well as to inform them about local help and services.
      
   5. Physicians should be aware of social, community and other services of use to victims of violence, and refer to and use these routinely.
      
   6. Physicians should be acutely aware of the need for maintaining confidentiality in cases of family violence and should be knowledgeable about adequate case documentation and any local or national reporting requirements.
      
   7. Physicians should be encouraged to participate in coordinated community activities that seek to reduce the amount and impact of family violence.
      
   8. Physicians should be encouraged to develop non-judgemental attitudes toward those involved in family violence so their ability to influence victims, survivors and perpetrators is enhanced. For example, the behaviour should be judged but not the person.
7. National Medical Associations should encourage and facilitate coordination of action against family violence between and among components of the health care system, criminal justice systems, law enforcement authorities, family and juvenile courts, and victims' services organizations. They should also support public awareness and community education.
   
8. National Medical Associations should encourage and facilitate research to understand the prevalence, risk factors, outcomes and optimal care for victims of family violence.

13.10.2006