I provide supportive services to victims of crime, from the vantage of a Victim Services Unit within the Criminal Investigations Bureau of a large police department. The painful, chilling, and humiliating abuse of the human body and spirit is a major element of my daily journey. I have witnessed firsthand the pollution that violent crime leaves in its wake. I often feel as though I am trapped in the belly of the whale—some large, powerful animal that thrashes about—so large, in fact, that it encompasses every aspect of the criminal justice system from the moment the crime occurs throughout its aftermath—while trying to help small fish swim out into safe waters. Through police-based victim service programs, victim advocates provide immediate and direct services and possible solutions to a victim’s conflict. Working from within the system, one sees what victims of crime—most of them solid citizens, ordinary people living each day, just like you and me—encounter when faced with traumatic situations. For unsuspecting victims, crime is an ugly reality of circumstance that landed them in their own personal chamber of horror.

Imagine what a victim of sexual violence experiences when being forced by a rapist to submit to a physical act so degrading and abusive that it causes a disconnection from all previous coping techniques for survival. The criminal act is animalistic, nauseating, frightening, controlling, injurious, and painful. Victims of sexual violence experience the criminal act on several levels: the rapist not only invades and destroys the victim’s innermost privacy, body parts, and concept of self but is also a robber who damages and steals property. And the criminal act is only the beginning. If the truth is to be known to the system, then rape victims must report the crime. For many victims, the decision to report the crime is overshadowed by their fear of revictimization at the hands of the system. Rape victims, for instance, must submit to an investigation that is not always sensitive and often begins with being told not to wash, shower, rinse, urinate, or remove their clothing until their body (which is evidence) and their clothing (which is evidence) can be “processed.” Injury, disease, and pregnancy are immediate concerns and all too often become reality for some victims. The rape victim, regardless of age or gender, is again forced to submit, this time to an examination, which generally includes consenting to the photographing of intimate body areas. The victim is made aware that the photographs may be used as evidence in a court of law. A rape victim must submit to being touched by a medical examiner in places the rapist defiled and degraded. This early medical procedure is the victim’s introduction to the legalities of the criminal justice system. Victims become aware that they are “cases” requiring study, examination, and analysis. All these procedures must occur before the victim can finally retreat to the privacy of a shower stall or bathtub to wash away the ravage of the event and the
strain and stress of the examination. This process is taxing and dehumanizing; yet it is also a necessary component of the total response to the victims of sexual violence, and it should be conducted with sensitivity and expertise. Medical professionals are trained and skilled in helping victims withstand the process. Still, there is no preparation, planning, or training for the victim, who is at the center of the process and of all subsequent system responses.

It is not enough to deal with the trauma of physical injury from violence. Victims must also cope with the aftermath of the experience, and effective systems must work together to intervene with support, solution, and justice. Victims of crime experience extended trauma, which must be recognized as an area for scientific study, leading to a systematic approach that will enhance our current methods of addressing the needs of victims. Medical systems provide sensitive and expert assistance to sexual assault victims. Victims report they are being helped through medical examinations with compassion and discernible explanations of the procedure and the necessary aftercare.

Victims of domestic violence withstand bodily injury in the form of bruises, lacerations, broken noses, loss of eyesight, burns, broken limbs, punctured eardrums, and other disfigurements. The victims of this type of crime are seen most often in emergency departments, by family doctors, and in health clinics. Yet, too many physicians treat only the illnesses and injuries associated with the violence; in some cases, physicians fail to identify the violence. Even when violence has been recognized, too many physicians do not have adequate training or education that enables them to respond appropriately to the insidious problem of violent relationships. The victim is sometimes unable to share information with the physician because the batterer may be present. The victim may be unaware of the principle of patient confidentiality and is probably operating under the batterer’s constant threat to life.

Domestic violence victims are often caught up in a complex relationship, in which abuse occurs on several levels: violent behavior, emotional cruelty, psychological threats to the victim and other family members, and financial/economic abuse. Although there are numerous theoretic explanations for the causes of domestic violence, no one theory is generally agreed on because of the dynamics involved in each abusive relationship. Victims suffer from feelings of shame and humiliation; as a consequence, they are frequently reluctant to discuss the abuse in some instances, particularly with a physician whose efforts they believe are directed toward mending the wound and not necessarily its cause.

One of the most tragic examples of system failure involved a woman who was tortured over a number of years by her husband. He inserted objects into her vagina and pulled large chunks of her hair from her head. He punched, kicked, and slapped her, particularly in the lower back area, and she was often treated for what they both described as her tendency to fall due to clumsiness. This victim was treated for kidney problems and other complaints over a 2-year period without any inquiry about domestic violence. The victim finally left her abuser, who resorted to stalking her in an attempt to regain the control that he needed. As she entered the parking lot at her place of employment one morning, her husband inflicted a fatal stab wound to her abdomen.

After deciding to leave the abusive situation, this woman had sought help from local authorities, used the system for protective orders, discussed her fractures with her doctor, informed her place of employment about her husband’s behavior, and even developed safety plans. Despite the abuser’s intent to destroy her, this victim might have been saved through early detection of danger, recognition of indicators, appropriate system intervention to address the abuser’s behavior, and effective safety support strategies that included collaborative efforts by allied professionals. This case also represents a system that failed to remove the abuser from the home, recognize his behavior as being criminal, and support the victim’s attempts to escape the situation. All too often, such abuse is undetected by the system until it reaches monumental proportions.

Coupled with domestic violence is the sinister crime of stalking, which involves conduct and behavior by the stalker directed at a person with the intent of having the person fear for his or her safety and/or that of family members. Stalking is the act of repeatedly following, viewing, telephoning, writing letters, and indulging in other types of threatening behaviors intended to control, create fear in, and “possess” the victim. Domestic stalking, or the stalking of domestic violence victims, generally occurs after the victim has ended the relationship with the stalker. The victim is stalked as if for revenge for having left the offender.

Victims of domestic violence seek help from medical professionals more often than from any other type of support and care. Health care professionals are in a prime position to identify the dynamics of domestic violence through careful examination of certain symptoms, reactions, and indications, which will alert them not only to physical violence but also to emotional and sexual abuse. Recognizing that medical illness and physical injury can result from domestic violence and that proper medical intervention can prevent further violence and its consequences, the American College of Emergency Physicians encourages emergency personnel to screen patients for domestic violence and offer
contact information about local shelters, advocacy groups, and legal assistance to patients who are or may be experiencing domestic violence (2).

The health care approach of prevention, prevention/intervention during the early stages of a medical condition, followed by treatment/prevention is now being applied successfully to combat the global problem of domestic violence. To this end, great strides have been made in educating the public about the gravity of this form of criminal behavior. Special programs have been developed to meet the needs of victims of domestic/family violence, yet more effort is needed to overcome the centuries of acceptance of violent behavior toward women. The goal is to permeate and saturate cultural thinking to a state of intolerance to violent behavior of any sort. The enormous problem of domestic/family violence is still fueled by its cultural entrenchment (attitudes that foster and perpetrate violence toward women) and the lack of consistent response to the violence. Consistent health care responses by professionals along with all other responding agents (including protocols, procedures, and policies for victim care) must be in place throughout the nation.

The elderly are victims of crime less often than other age-groups. When they are abused, they are subjected to a dehumanizing denial of dignity as they strive to adjust to the aftermath of crime. They can suffer from different forms of exploitation coupled with physical and sexual abuse and neglect imposed by caregivers, who are frequently family members. Is there a greater insult than to live a long life with an expectation of peace, safety, contentment, and integrity in the final stages of life, only to have these longings destroyed by callous, violent behavior? Erikson’s identification of the core crisis of the elderly—integrity versus despair—takes on a greater dimension in the face of crimes against this age-group. Those who feel few regrets achieve ego integrity; they have lived productive and worthwhile lives and have coped with their failures and their successes (3). The failure to achieve integrity leads to feelings of despair, hopelessness, guilt, resentment, and self-disgust. In the aftermath of violent crimes, elderly victims can experience intense feelings of isolation, be hampered in their ability to care for their spouse, face reduced income, and feel increasingly dependent on others.

Recognition of elderly crime victims and interventions for their care have increased; as a result, the specific problems of this group of victims are now being addressed. Domestic violence, sexual assault, and even murder are still often overlooked because of factors commonly associated with age. The medical profession must lead in the effort to ensure that the elderly population is understood. Elderly victims may be forced to live with family members or in respite care following victimization. For the elderly, such major life changes can affect their independence and concept of self. Diminished physical abilities, frailty, decreased financial resources, and loss of mobility are all issues to be considered when treating elderly victims.

Children also are victims of physical assault, sexual assault, neglect, and emotional trauma. They suffer abuse at the hands of parents (male and female), relatives, caregivers, and strangers. Witnessing violent episodes in the home among family members/household members imposes a tremendous psychological toll on children and increases their risk for behavior problems as they develop and grow into adulthood. Without therapeutic intervention, many abused children will grow up to become abusers or candidates for serious revictimization (4). It is intolerable that so many children witness sexual violence, physical assault, domestic violence, and even murder. Their lives are affected by what they see, and, unless intervention occurs at an early stage, the effects can be long lasting.

One of the pioneers in bringing the tragic world of child abuse to the attention of pediatricians in particular and the medical community in general is Martin Finkel, founder of the Camden County Coalition Against the Sexual Abuse of Children (in New Jersey). For more than 20 years, Dr. Finkel has aimed to improve the “system” through research and the provision of direct services to abused children (5). His staff of clinical psychologists, pediatricians, researchers, support staff, and outreach personnel work together to address the immediate problems of each child while providing help that can avoid the predictable outcomes of child sexual abuse.

In their book The Anatomy of Motive, Douglas and Olshaker proclaim that every crime is a mystery story with a motive at heart, which can often explain violent sociopathic behavior (10). They expose the devious nature of violence and the irreversible harm it causes to the recipients. In their discussion of predatory behavior, they conclude that criminals, despite family background, intelligence, or emotional stability, choose to commit their acts of violence. Certainly, deviant behavior, as a choice that results in abuse and injury, is as old as recorded history. The magnitude of these choices continues to be grave, complicated, distressing, and of tremendous concern to society. Human violence remains the same: a manifestation of senseless, bizarre, incomprehensible acts inflicted on people who become victims of heinous crimes. From a historical perspective, most societies developed basic response systems for the management of violent behavior. However, early response systems were never adequate to address the length and breadth of violence in any society. Today, because of the combined efforts of criminal justice agencies, medical and mental health professionals, and members of the faith, business, educational, and legal communities, our response systems are making a difference in the lives of crime victims.

Violence, even as a means to achieve socially acceptable ends, is destructive, deprecating, dominating, painful, and, most importantly, unnecessary in any context. Criminologists, forensic psychiatrists, and correctional professionals can help us understand violence, but they often view the problem from their own field, which tends to preclude awareness of the lasting effect of violence on its victims. Dr. James Gilligan, former medical director of Bridgewater State Hospital for the Criminally Insane, believes that different forms of violence are motivated by shame. The purpose of violence is to diminish the intensity of the perpetrator’s shame and replace it with the opposite feeling, pride (9). Conversely, victims of violence frequently experience feelings of shame, anger, rage, low self-esteem, helplessness, and defeat as a result of the perpetrators’ efforts to eliminate their own uncomfortable feelings at the expense of the victim. For victims, the exposure creates a lasting relationship with perpetrators and their deeds. Such an injustice is not singular but is perpetrated on the entire society and is, quite simply, an outrage. Further outrage is that for every reported case of violence there are countless numbers of cases and instances of violent crimes in these categories and others that are not reported through the established gates of entry for help. The medical profession should be the gatekeeper for those victims who out of necessity seek medical help. Early detection of abuse, particularly in children, will diminish the number of children forced to live with the pathology of criminal behavior. The insult of victimization demands not only moral and legal consideration but also response to the causes of violence, treatment of the causes, and utilization of this knowledge to prevent further violence.