FAMILY VIOLENCE AND THE HEALTH CARE SYSTEM
EXECUTIVE SUMMARY

1. A Severe Problem that Affects Everyone Family violence in Texas has reached epidemic proportions and continues to grow. It is a significantly more serious problem than most persons expect, particularly given decreases in overall rates of violence in recent years. Children, the elderly, and intimate or cohabiting partners are especially vulnerable to a range of violent acts in a wide variety of contexts. Acts and omissions resulting in physical harm to persons from all the above populations are included in our use of the term "family violence." Currently identified cases of family violence represent only the tip of the iceberg of actual cases. Texas leads the nation in rates of domestic violence. Violence against children in Texas is a severe problem and is getting worse by the year. Information about, and services for, victims of elder abuse is in the very early stages--comparable to the state of knowledge about child abuse 25 years ago. Contrary to public perceptions, family violence affects all aspects of society, crossing racial, ethnic, gender, and socio-economic boundaries.

2. Low Levels of Identification of Cases Large numbers of existing cases of family violence currently are not being identified and reported. Levels of identification of existing cases of violence are low among the elderly and are especially low for child abuse. Many persons in a good position to identify and report family violence are not properly trained to recognize signs of abuse. Enhanced education of professionals, such as physicians, dentists, nurses, teachers, and day care employees, has the potential to increase greatly the number of cases identified and prevented. Even though required by law, many professionals are not reporting recognized cases of family violence. For cases of child and elder abuse, mandatory reporting alone is inadequate to prevent continued violence. In contrast to other professions, law enforcement professionals in Texas are among the best trained in the nation on issues of child abuse.

3. Inadequate Social and Health Care Services

A. Social Services Services in Texas to assist victims of family violence, such as temporary housing and legal services to obtain protective orders, have never been sufficient to meet the needs of victims. Family violence is expected to increase substantially; better identification of cases will also contribute to these increases. Further, an imminent cut in federal funds of $30 million annually will put even more pressure on the overburdened system of services. Some Texas initiatives in limited areas have been highly successful in serving victims of family violence. These and similar initiatives need to be supported statewide. Problems of inadequate services exist in all populations vulnerable to family violence. In domestic violence, for example, there are more animal shelters nationally than shelters for women and children. Regarding elders, there is no effective mechanism to detect abuse in nursing homes or provide victim services. The lack of services for children to alleviate ongoing abuse makes them more likely to be chronically abused. Abused children are more likely to commit violent acts and other crimes when they grow older, to be disproportionately incarcerated, and to abuse their own children, thus perpetuating the cycle of violence.

B. Health Care Services Uncompensated trauma care for injuries due to intentional violence costs the citizens of Texas an estimated $68 million annually. Changes in health care financing are creating a financial crisis for many trauma centers because it is increasingly difficult to shift the high costs of trauma centers to other areas of hospitals. The burden of medical treatment for persons injured by family violence is severe and affects all Texans, by consuming scarce medical resources and overloading the capacity of existing trauma centers. There is an inadequate number and distribution of trauma centers in Texas to meet existing needs. The existing patchwork trauma "system" contains many unserved and underserved areas, resulting in unnecessary death and disability for many Texans and adding to the costs of publicly funded health care. A lack of willing and properly trained personnel has a negative impact on delivery of trauma care services. There is an inadequate number of surgeons willing to perform trauma surgery. Texas also lacks adequate resident physician training programs in the field of emergency medicine, resulting in a net outflow from the state of medical school graduates with an interest in emergency medicine. There is also a shortage in many areas of the state of Emergency Medical Services personnel (who provide prehospital treatment and transportation) and Emergency Medical Dispatch personnel (who answer emergency calls). Some of the identified deficits in education and training, as well as an increased need for consultation by physician specialists, could be addressed by a comprehensive statewide network of telecommunications technologies for purposes of distance learning and telemedicine serving rural and frontier areas.

4. A Fragmented Texas Response A major barrier to prevention of family violence and developing appropriate responses to existing family violence is a lack of coordination among the large number of Texas state agencies with contrasting and overlapping responsibilities for various aspects of the problem. Different state agencies have responsibilities in the areas of social services, law enforcement, data collection, violence prevention, professional education, and research. There is no effective mechanism to coordinate among Texas agencies a statewide response to family violence. The existing state response to family violence is thus fragmented, inefficient, duplicative, and incomplete.

5. Poor Data Many important questions that might be asked about the patterns, distribution, causes, and contexts of family violence cannot yet be answered with reasonable certainty because reliable information is limited in both quantity and quality. This lack of data is a serious barrier to prevention of family violence. Multiple existing data collection systems, including information from the fields of criminal justice and health care, are inadequate to measure violent incidents accurately and completely; these systems are not coordinated and compatible with each other. There is substantial noncompliance with reporting requirements to existing data systems. Although criminal justice data are widely available, their focus on the perpetrator does not convey an adequate picture of the emotional or financial costs to the victim or society.

Additional Legislative Action Needed

The Texas Legislature in the past has enacted legislation addressing some of these problems in the family violence field, for example, as a result of the work of the Senate Interim Committee on Domestic Violence in 1994 and the Senate Select Committee on Elder Abuse in 1987. Current legislation is not necessarily serving its intended function, however, and is insufficient to meet existing and future needs of the state. More needs to be done to address these issues.