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THE NEED FOR VICTIMIZATION SCREENING IN A POOR OUTPATIENT MEDICAL POPULATION Carl C. Bell, MD, Carolyn J. Hildreth, MD, Esther J. Jenkins, PhD, Deborah Levi, RN, MSN, and Cynthia Carter, BS Chicago, Illinois

Recent reports indicate that violence toward others is a major public health problem in the black community; however, there are few empirical studies that delineate the severity of the problem. The authors have compiled the results of a victimization screening form obtained from a poor outpatient medical population. These results are compared with a similar survey performed on a poor outpatient psychiatric population. Recommendations are made that poor medical populations should be screened for histories of victimization, because early identification of patients at risk may reduce their chances of future victimization.

In 1986 blacks accounted for 44 percent of the murder victims in the United States, and, as in previous years, 95 percent of the black victims were slain by black offenders.' Partly responsible for this disparity is the fact that blacks are disproportionately represented among perpetrators and victims of spouse killings.2'3 As a result, domestic murder, which often stems from family violence, is a significant contributor to the high murder rates in blacks. From the Community Mental Health Council, Inc, Chicago. Requests for reprints should be addressed to Dr. Carl C. Bell, Executive Director, Community Mental Health Council, Inc, 8704 S Constance Ave, Chicago, IL 60617.

It has been estimated that 30 to 40 percent of the women murdered in the United States are killed by their husbands or lovers, usually after being beaten by those men for years. 4 Unfortunately, wife beating is the most common but least reported crime in the United States.4 Straus et a15 estimated that each year 15 to 30 percent of US couples experience marital violence, and each year about 2 million women are beaten by men. This study also estimated that one half of all married women experience physical violence at least once during their marriage. More recently, Straus and colleagues6 have estimated that 1.5 million women receive medical attention because of an assault by a male partner each year. Stark and Flitcraft7 estimated that 3 to 4 million women are beaten each year, with battering accounting for one of every five visits by women to emergency services and half of every injury episode. They also noted that battered women suffer more frequently from general medical problems, rape, and psychological symptoms of stress, such as suicide attempts, alcoholism, drug abuse, and depression. Because nonlethal violence is a frequent antecedent to homicide6 and because blacks have disproportionately higher rates of domestic murder, one would expect that domestic violence in blacks would also be disproportionately higher than in whites. However, the studies on domestic violence and abuse of women conflict on this point. For example, Straus et al5 found that abuse of women occurred three times more often in blacks than in whites. Contrary to that observation, the Department of Justice found no difference in the

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 80, NO. 8, 1988

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VICTIMIZATION SCREENING

victimization rates of blacks and whites for violent crimes by spouses or ex-spouses; however, blacks reported violence by relatives other than spouses to a higher degree than did whites.8 The reasons for these disparities are unclear but may have to do with other variables that are more prevalent in blacks compared with whites, such as unemployment status, poorer educational opportunities, lower class status, and lower incomes.9"10 Arguments and altercations between relatives and friends are frequent precursors to homicide." 2'5" 1-13 Further, several studies'4" 5 have shown that perpetrators and victims ofhomicide have histories of more frequent fighting than controls. The rate of aggravated assault victimization is higher among blacks, resulting in physical injury being more common in blacks and low-income victims of assault.'2 Although only 1 percent of gun robberies lead to a death, robbery is a violent crime, with rates of robbery being higher for men, blacks, and the unemployed. As a result, robbery is still very physically and psychologically damaging to the black community.'2 Yet very little is known about the effects of the higher robbery rates on the physical and psychological health of blacks. For example, posttraumatic stress disorder is known to occur in robbery victims, but how often it occurs is unknown. Forcible rape is another violent crime that, although it rarely results in death, exacts a heavy toll on society. Several studies note a high prevalence of sexually abused women in psychiatric populations and propose that their sexual abuse may have etiological significance in their psychiatric disorders.'6-'8 In summary, violent crime is a serious problem in America. It causes high rates of mortality and physical and psychological morbidity. A murder occurs every 25 minutes; a forcible rape occurs every 6 minutes; a robbery occurs every 58 seconds; and there is a victim of aggravated assault every 38 seconds.' There is every reason to believe that poor people and blacks are at even greater risk from these violent crimes. Despite the gravely serious implications of these findings for the medical community that treats the victims of these violent crimes, the medical community seems wholly unaware of the prevalence of victimization in their patients. As a result, the medical community has been negligent in developing strategies and interventions to reduce the problem of violent crime in society; this has been especially true for the problem of violent crime in the black community. Because the early identification of violence allows 854

for interventions that may preclude a future homicide, the investigation of the prevalence and dynamics of violence should be a major priority. Because homicide rates are higher among blacks and low-income persons, studies of blacks and low-income populations should receive first priority. '1-3 It is extremely important that the medical profession take the lead in such investigations, since physicians and other health professionals are responsible for treating the damage that stems from domestic violence. Taking a public health philosophy toward violence is especially crucial since, according to the FBI, ". . . the fact that three out of every five murder victims in 1986 were related to ( 16 percent) or acquainted with (42 percent) their assailants . . ." supports the ". . . philosophy that murder is primarily a societal problem over which law enforcement has little or no control. .. The purpose of this paper is to present some research findings on the prevalence of victimization in a poor predominantly black outpatient medical population. These results are contrasted to a similar study in a black outpatient psychiatric population. 16 Finally, recommendations are made on how the medical profession can begin to intervene to prevent further victimization of the patients for which it cares.

METHODS Sample A total of 262 patients at a neighborhood outpatient medical center were screened for the study. The sample was 80 percent black, about 13 percent Hispanic, and 5 percent white and other. Their ages ranged from 4 to 80 years, with 59 percent of the sample aged 18 years and over. Of the 155 patients over 18, the vast majority were female (n = 141). The clients younger than 18 were more evenly split between boys (n = 42) and girls (n = 65). All of the respondents were visiting a neighborhood medical clinic on the near North Side of Chicago, in an area that is predominantly black, Hispanic, and poor. The clinic has a total yearly patient population of 16,000, 78 percent of whom receive either Medicare/Medicaid or pay a minimal fee. Over the twomonth period when the data were collected (JulyAugust), the agency saw 6,359 patients, 66 percent of whom were black and 29 percent Hispanic. Thus, blacks were somewhat overrepresented in the study's sample and Hispanics (despite a Spanish-language version of the screening form) were underrepresented.



TABLE 1. MEDICAL OUTPATIENT AND PSYCHIATRIC OUTPATIENT VICTIMS, AGE 18 AND OLDER

Psychiatric Outpatients

Medical Outpatients

Personally Molested Raped Robbed Robbed with weapon Assaulted

Female No. (%)

Male No. (%)

Total No. (%)

Female No. (%)

Male No. (%)

(n = 141) 19 (14)

(n = 14) 0 (0) 0 (0) 5 (36) 4 (29) 5 (36)

(n = 155) 19 (12) 19 (12) 34 (22) 15 (10)

(n = 220) 70 (32) 73 (33) 96 (44) 23 (10) 88 (40)

(n = 123) 12 (10) 5 (4) 51 (41) 27 (22)

19 (14) 19 (21) 11 (8) 21 (15)

26(17)

50(41)

Total No.

(%)

(n = 343) 82 (24)

78 (23) 147 (43)

50 (15) 138 (40)

(n = 123) (n = 343) (n = 154) (n = 220) (n = 140) (n = 14) Know of Someone* 17 (14) 7 (50) 48 (22) 21 (15) 28 (18) 65 (19) Molested 64 (29) 31 (20) 17 (14) 81 (24) 5 (36) 26 (19) Raped 7 (50) 79 (36) 121 (35) 60 (43) 56(44) 42(34) Robbed 5 (36) 48 (31) 73 (33) 105 (31) 43 (31) 32(26) Assaulted 6 (46) 87 (25) 44(29) 55(25) 32(26) Murdered 39(28) * Number of female medical outpatient respondents, 140; male medical outpatient respondents, 14; total medical outpatients, 154.

An analysis of the client population indicates that women over the age of 18 years were also somewhat overrepresented (by 20 percent), and youths less than 18, who made up over 60 percent of the agency's caseload, were underrepresented.

Procedure Adult patients in the waiting room of the clinic were approached by an interviewer (a fourth-year medical student or a nurse) who explained the nature of the study and requested the participation of the individual and his or her children. Consenting patients either completed the Victimization Screening Form themselves or had the form administered to them by the interviewer; all children younger than 16 years were administered the form. Parental consent was obtained for all children younger than 18 years. Originally developed for use with a mentally ill population, the Victimization Screening Form is a one-page questionnaire that asks about the incidence of sexual and physical victimization of the individual and the victimization of relatives, neighbors, and friends of the individual.'6 Specifically, the form asks whether the individual and close others have ever been molested, raped, robbed, robbed with a weapon, or physically assaulted. In addition, the form asks whether a close other has ever been murdered.

RESULTS Adults Reported victimization of adult female and male patients, and of individuals close to them, is presented in Table 1. Responses for black, white, and Hispanic patients are combined because analyses indicated no significant differences between these groups. Analyses are reported separately for women and men. Women. Approximately one in seven of the adult women indicated that they had been molested (14 percent), and similar numbers had been raped (14 percent) and physically assaulted ( 15 percent). Looking at the number ofpatients who had been victimized (as opposed to isolated incidents that may have been reported by the same individuals), 6 percent (n = 8) of the women had been sexually assaulted, 7 percent (n = 10) had been physically assaulted, and 8 percent (n = 11) had been both sexually and physically assaulted. Thus, a total of 21 percent, or roughly one in five, of the women had experienced sexual and/or physical assault. Approximately one in five of the women indicated that they had been robbed, and over one half of the 29 robbery victims indicated that a weapon had been used. All of the women knew of a relative, neighbor, or friend who had been victimized. Fifteen percent (n = 21) of the women reported that someone close to them had been molested, and 19 percent (n = 26)


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TABLE 2. MEDICAL OUTPATIENT AND PSYCHIATRIC OUTPATIENT VICTIMS, AGE 17 YEARS AND YOUNGER

Psychiatric Outpatients

Medical Outpatients Female No. (%)

Male No. (%)

Total No. (%)

Female No. (%)

Male No. (%)

Total No. (%)

Personally Molested Raped Robbed Robbed with weapon Assaulted

(n = 65) 5 (8) 2 (3) 4 (6) 1 (2) 12 (18)

(n = 42)

(n = 107) 5 (5)

(n = 30) 6 (20)

(n = 54)

2(2) 8 (7) 1 (1) 19 (18)

4(13) 1 (3) 1 (3) 10 (33)

1 (2) 10(19) 4 (7) 21 (39)

(n = 84) 9 (11) 5 (6) 11 (13) 5 (60) 31 (37)

Know of Someone Molested Raped Robbed Assaulted Murdered

(n = 50)

(n = 33) 1 (3) 3 (9) 9 (27) 11 (33) 3 (9)

(n = 83)

(n = 30)

(n = 54)

(n = 84)

7(14) 7 (14) 19 (38) 22(44) 13 (26)

0 (0) 0 (0) 4 (10) 0 (0) 7 (17)

knew of someone who had been raped. Sixty (43 percent) of the women reported that a close other had been robbed, 43 (31 percent) knew of someone who had been physically assaulted, and 39 (28 percent) reported that a close other had been murdered. Men. Only 14 adult men visited the clinic and completed the screening form. Ofthose 14, none had been sexually victimized (molested or raped) but over one third (36 percent) indicated that they had been physically assaulted, and the same number indicated that they had been robbed. Four of the five robbery victims reported that a weapon had been used. A relatively high percentage of the men reported that someone close to them had been victimized. One half (n = 7) of the men knew of someone who had been robbed, and six (46 percent) reported that someone close to them had been murdered. Five (36 percent) each knew of someone who had been raped and physically assaulted. A comparison of male and female subjects suggests different victimization experiences, although the differences, with one exception, were not statistically significant. Only women reported sexual victimization, whereas men were twice as likely to report that they had been assaulted and were 1.5 times more likely to report that they had been robbed. Men were also more likely to report that a close other had been victimized and were significantly more likely to report that a close other had been sexually molested (X2 = 8.25[l], P < .01). 856

8(10) 10 (12) 28 (34) 33 (40) 16 (19)

6(20) 8(27) 10 (33) 9 (30) 7 (23)

3 (6)

6(11) 11 (20) 4 (7) 13 (24) 5 (9)

12(14) 19 (23) 14 (17) 22 (26) 12 (14)

Youth Data on male and female medical patients under the age of 18 years are presented in Table 2. Similar to the findings for adults, only female patients reported instances of sexual victimization; five (8 percent) of the young women had been molested and two (3 percent) had been raped. Four male (10 percent) and four female patients (6 percent) had been robbed, but only one, a 16-year-old girl, reported that a weapon had been used. The boys and girls were almost equally as likely to report that they had been assaulted (17 and 18 percent, respectively). (In the minor's questionnaire, the word "whipped" was used to clarify the term physical assauilt; therefore, it is unclear how many of these reported "assaults" were reasonable disciplinary actions taken by family members [eight were specified as such] and how many were actual physical assaults.) Data from 83 of the youths on the victimization of close others are also included in Table 2. In comparison to boys, girls were more likely to know of the victimization of close others in all of the five areas, and were three times more likely to report that a close other had been murdered. A comparison by age found that male adults were significantly more likely than boys to have been robbed (X2 = 3.57[1], P < .05) and to know of someone who had been molested (X2 = 12.20[ 11] P < .00 1) and murdered (X2 = 5.95[I], P < .01). Female adults



were significantly more likely than girls to have been raped (X2 = 4.18[l], P < .05) and robbed (X2 = 5.84[1], P < .01).

Comparison of Medical and Psychiatric Outpatients Recently, Bell et al'6 reported the results of a victimization screening of 427 psychiatric outpatients. That data indicated that the mentally impaired experienced considerable victimization, with almost one half of the adult clients reporting sexual and/or physical assault. Data from the current survey of medical (MED) patients were compared with those from the psychiatric (PSY) group so as to gain a better perspective on both. Analyses were done separately for the female and male adults and for girls and boys younger than 18 years. The results indicate that, in general, the mentally ill were significantly more likely to be victimized. This was particularly so for female adults (Table 1). The female PSY outpatients, compared with the adult female MED patients, were more than twice as likely to have been sexually molested (X2 = 16.49[1], P < .001), more than twice as likely to have been raped (X2 = 16.41[1], P < .001), and more than twice as likely to have been robbed (X2 = 18.62[1], P < .001). They were more than 2.5 times as likely to have been physically assaulted (X2 = 23.7 1[1], P < .001). Consistent with the notion that the mentally ill are more likely to be victimized because they are vulnerable and are more vulnerable because they pose less of a threat to their attacker was the finding that the female PSY outpatients were more likely to have been robbed, but the female MED patients were significantly more likely to have been robbed with a weapon. Of the 21 female MED patients who had been robbed, 1 1 (51 percent) indicated that a weapon had been used, compared with 23 (24 percent) of PSY female patients who had been robbed (X2 = 23.7[1], P < .001). Although these women did not differ significantly in their knowledge of the victimization of close others, PSY women were somewhat more likely to report that a close other had been sexually victimized, whereas more MED women reported that a close other had been robbed. The two groups of women were about equally as likely to know of someone who had been assaulted or murdered. Although a reliable comparison of male adults is difficult due to the small number of male medical

patients, the figures suggest that PSY and MED male adults experience, or at least report, comparable levels of personal victimization. However, male MED patients were more likely than male PSY outpatients to indicate that a close other had been victimized and were significantly more likely to indicate that a close other had been sexually victimized. Nonpsychiatric patients were 3.5 times more likely to know of someone who had been sexually molested (X2 = 11.41 [1], P < .001) and 2.5 times more likely to have had a close other raped (X2 = 4.47[l], P < .05). A comparison of the young medical and psychiatric outpatients indicates that, in general, the PSY youths were more likely to report personal victimization (Table 2), although few of the differences were statistically significant. Girls at the mental health center were 2.5 times more likely than girls visiting the medical clinic to have been molested and more than four times as likely to have been raped. Young women from the mental health facility were more likely to have been assaulted, but the medical outpatients were twice as likely to have been robbed. Just as the PSY girls were more likely to have been raped and molested, more of them also reported that they knew of someone who had been raped and molested. More MED girls reported that someone close to them had been assaulted, but comparable numbers in both groups knew of someone who had been murdered. Twenty-three percent of the PSY girls and 26 percent of the MED girls reported that a relative, friend, or neighbor had been murdered. Among boys, the PSY outpatients were more likely to have been victimized and were significantly more likely to have been assaulted (X2 = 5.6[1], P < .05)even considering the somewhat inflated numbers for the MED youths mentioned previously. Similar to the girls, more PSY male patients knew of someone who had been molested and raped, but the young men from the medical center were significantly more likely to report that a close other had been robbed (X2 = 6.39[1], P < .05) and somewhat more likely to have known of someone who had been assaulted. Interestingly, PSY and MED male youngsters were equally likely to report that a close other had been murdered. This percentage (9 percent) is considerably lower than that for girls or male and female adults from either group and raises some interesting questions about young male blacks' perception and recall of threatening events.


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DISCUSSION The sample of 262 patients represents approximately 4 percent of the patient population seen during the two months of the study. Although patients were requested to participate in the screening randomly, the sample is not representative because the patients had the option of refusing to participate, which made the study sample self-selected. Hispanics seemed reluctant to participate despite a Spanish version of the screening form, and as a result were underrepresented. Children were also underrepresented due to the technical difficulty of getting their parents' consent to allow them to participate in the study. Thus, the sampling procedures used in the study were influenced by a number of extraneous variables that could not be controlled, and any discussion of the findings must consider this factor. Despite this shortcoming, the authors feel that the data gathered from this survey have heuristic value. The adult women who participated in the screening reported a significant amount of sexual and/or physical assault and robbery, and an even greater percentage of women knew of others who had been similarly victimized. In contrast, while over one third of the adult men reported physical assault and robbery, none reported being sexually assaulted; yet adult men were significantly more likely than women to report they knew of someone who had been sexually molested. Like the adults, the girls screened for victimization reported a significant incidence of sexual assaults, while the boys denied such events. The finding that women reported experiencing more sexual abuse than men is not surprising, as women are more often the target of such attacks. However, the finding that none of the men reported experiencing a sexual assault contradicts other studies on the subject. Risin and Koss'9 reported that 7.3 percent of their male sample experienced an abusive sexual experience before the age of 14. This figure is consistent with Finkelhor's20 study that revealed 6.4 percent of boys under 14 had been sexually victimized. The authors suspect that the lack of reporting of sexual victimization in this predominantly black male sample was due to a significantly greater difficulty in admitting such an emasculating event and to the lack of a stable clinical relationship with the screening professional. The finding that this population experienced significant amounts of robbery (with and without a weapon) and physical assault is not surprising since 858

victimization rates for these crimes are high for poor people and blacks. Similarly, the finding that men report more robbery, robbery with a weapon, and physical assault than women is also not unusual because men are more frequently robbery and assault victims, and the less vulnerable the robbery victim, the more likely the robbers will wield a weapon in the robbery.'2 What is unexpected is that more adult men than adult women knew of someone who had been sexually molested. The authors suspect that men may know more victims of sexual assault because men are usually the perpetrators of such assaults and as a result may have more knowledge of such attacks. They may also have less of a reason to deny such threatening events, while women may not discuss such issues in an effort to deny the danger. The issue of denial is again raised by the finding that young girls knew of significantly more murder victims than young boys, which may be due to the boys' denial of the risk of murder. Rates of reported robbery and physical assault were low in both the girls and boys (several children included spankings as physical assaults, so this category may be exaggerated for the children). Finally, in looking at age as a variable, it appears that as men get older their chances of getting robbed increase, and their awareness of sexual molestation and murder in others increases; older women have a greater chance of being raped and robbed. Thus, growing up in a predominately poor minority community is fraught with recognizable real dangers, which may be denied or faced at different ages for different sexes. In comparing the reports of victimization between the medical and psychiatric patients, some interesting differences become apparent. First, the economic indicators on both populations reveal that a greater proportion of the MED patients screened were poor when compared with the PSY population. Thus, while poverty may be a predisposing factor for some types of victimization,'2 adult PSY women patients (who were economically more well off) were more likely to be victimized (molested, raped, robbed, and physically assaulted) than adult MED women. However, adult medically ill women were significantly more likely to be robbed with a weapon, a finding consistent with the literature, which indicates more "difficult" victims are likely to be robbed with a weapon.2' These findings suggest two possibilities. First, it could be that being victimized increases the risk that an individual will develop a mental illness, and as a



result, when doing screening for victimization in a mentally.ill population, more episodes of past victimization will become apparent. Second, these findings could also indicate an additional dynamic suggested by Bell et al,'6 which suggests that mentally ill patients may be perceived as more vulnerable to perpetrators and thus are more likely to be victimized. Another interesting finding is that although the mentally ill women were significantly more likely to be victimized, the medically and mentally ill female adult population did not significantly differ in their knowledge of others who had been victimized. Thus both populations have a similar view of risks of victimization to others while having a different personal experience. How this influences their self-protection behaviors is not clear and needs further investigation. Unlike medically ill men, the mentally ill men were willing to admit sexual assault at levels similar to other reports in the literature previously cited. Despite a lack of personal experience with sexual assault, nonpsychiatrically ill men reported significantly more knowledge of others who had been molested than psychiatrically ill men. The authors speculate this finding may again be related to the nonpsychiatrically ill men having more personal knowledge of such assaults as either perpetrators or confidants of perpetrators. Similar to the adults, psychiatrically ill youths were more likely to have been victimized. This initial pilot study on screening for victimization in a medically ill population has some important implications for a public health approach to handling what the surgeon general has called a major public health problem-violence toward others.22 First, there is very little empirical epidemiologic research on victimization in a medically ill minority population, although minority populations are at significantly greater risk for a number of violent crimes due to the inordinately high proportion of minorities who are poor. More data need to be collected, as it is evident there is a considerable area to be explored. Because reporting sexual assaults is a difficult task, the authors suspect both the adults and children underreported their experiences. However, because histories of physical or sexual assault are not often elicited in routine clinical assessments23 and because standardized screening offers an opportunity to regularly inquire about an assault history, the authors recommend screening, as underreporting is better than no information at all. In addition, it is the authors' experience that as a clinical setting gets known

for being seriously concerned about issues of victimization in its patients, it becomes more acceptable to discuss such previously taboo subjects. Second, by instituting routine screening, it becomes possible to identify victims who are not identified in routine clinical assessments. Once identified, more in-depth information can be obtained and various secondary prevention efforts can be begun to reduce future morbidity and mortality from a past assault or a future one. For example, such screening could begin to identify battered women who seek medical services for their injuries or distress from battery. Next, a handbook on victimization4 could be given to the woman along with a referral to a victim's service program. Of course this would entail medical facilities establishing a solid relationship with such services. Such a case finding and referral procedure may help to reduce future domestic violence in blacks,24 as well as homicides from domestic and peer violence. Similarly, such screening may allow for early intervention in a number of medical and behavioral problems that seem to stem from victimization. Problems such as suicidal ideation and attempts, 182526 nervous breakdowns 18,25,26 drug abuse,27 juvenile delinquenCy,27 criminal behavior,'8'27 self-destructive behaviors (biting, cutting, burning, head banging, suicide attempts) in children,28 assaultive behaviors,18 psychosomatic symptoms,7"8 depression,29 alcoholism,7 and sexual problems27 have all been reported as stemming from sexual and physical abuse. Screening may allow for early intervention in such medical and behavioral problems that result from victimization. Further, the recognition of the problem ofviolence by institutions in the community adds to the influence exerted to reduce violence in the community. Such an attitude ofviolence prevention enhances the feeling of safety in a clinic and the community and may encourage minority patients to stick with a regular source of health care. However, to have such an impact the overall policy of the institution has to support such screening, and implementation must be encouraged. Annual victimization updates are important to pick up new cases, but, again, policy has to be introduced and enforced in order for staff to get involved before the intrinsic value of the screening becomes evident to them. Finally, outcome studies of what impact screening has on prevention need to be performed. In conclusion, this study indicates physicians should screen for victimization in medical clinics and


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advocate for policy that supports such efforts. Finally, while it appears that psychiatrically ill patients are more likely to suffer from sexual and physical victimization, medically ill patients still have a high prevalence of such victimizations. Such patients should be identified so secondary and tertiary prevention of future victimization can be provided and the morbidity and mortality associated with previous sexual and physical assaults can be reduced. Acknowledgment The Near North Health Service Corporation staff assisted in the completion of this study.

Literature Cited 1. Federal Bureau of Investigation. Crime in the United States; 1986. Washington, DC: US Department of Justice, 1987. 2. Oliver W. Black males and the tough guy image: A dysfunctional compensatory adaptation. West J Black Studies 1984; 8:199-203. 3. Centers for Disease Control. Homicide Surveillance: HighRisk Racial and Ethnic Groups-Blacks and Hispanics, 1970 to 1983. Atlanta: Centers for Disease Control, 1986. 4. Illinois Coalition Against Domestic Violence. Handbook for Domestic Violence Victims. Chicago: Illinois Criminal Justice Information Authority, 1986. 5. Straus MA, Steinmetz SK, Gelles RJ. Behind Closed Doors: Violence in the American Family. Garden City, NY: Anchor Books, 1980. 6. Straus MA. Domestic violence and homicide antecedents. Bull NY Acad Med 1986; 62:446-465. 7. Stark E, Flitcraft A. Medical therapy as repression: The case of the battered woman. Health Med 1982; Summer/Fall: 29-32. 8. Klaus PA, Rand MR. Bureau of Justice Statistics Special Report: Family Violence. Washington, DC: US Department of Justice, 1984. 9. Barnhill LR. Clinical assessment of intrafamilial violence. Hosp Community Psychiatry 1980; 31:543-547. 10. Okun L. Woman Abuse: Facts Replacing Myths. Albany, NY: State University of New York Press, 1986. 11. Steinmetz SK. The violent family. In: Lystad M (ed). Violence in the Home: Interdisciplinary Perspectives. New York: Bruner/Mazel, 1986, pp 51-70. 12. Dietz PE. Pattems in human violence. In: Hales RE, Frances

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AJ (eds). Psychiatric Update: The American Psychiatric Association Annual Review, Vol 6. Washington, DC: American Psychiatric Press, 1987, pp 465-490. 13. Costantino JP, Kuller LH, Perper JA, et al. An epidemiologic study of homicides in Allegheny County, Pennsylvania. Am J Epidemiol 1977; 106:314-324. 14. Rose HM. Black Homicide and the Urban Environment. US Department of Health and Human Services, National Institute of Mental Health. Government Printing Office, 1981. 15. Dennis RE, Kirk A, Knuckles BN, et al. Black Males at Risk to Low Life Expectancy: A Study of Homicide Victims and Perpetrators. Project funded by NIMH grant No. 1 R01 MH36720. Washington, DC: Center for Studies of Minority Group Mental Health. 16. Bell CC, Taylor-Crawford K, Jenkins EJ, Chalmers D. Need for victimization screening in a black psychiatric population. J Natl Med Assoc 1988; 80:41-48. 17. Bryer JB, Nelson BA, Miller JB, et al. Childhood sexual and physical abuse as factors in adult psychiatric illness. Am J Psychiatricy 1987; 144:1426-1430. 18. Camen E, Rieker PP, Mills T. Victims of violence and psychiatric illness. Am J Psychiatry 1984; 141:378-383. 19. Risin Li, Koss MD. The sexual abuse of boys. J Interpersonal Violence 1987; 12:309-323. 20. Finkelhor D. Sexually Victimized Children. New York: Free Press, 1979. 21. Block CR. Lethal Violence in Chicago Over Seventeen Years: Homicides Known to the Police-1965-1981. Chicago: Illinois Criminal Justice Information Authority, 1985. 22. Koop CE. Surgeon General's Workshop on Violence and Public Health: Source Book. Washington, DC: National Center on Child Abuse and Neglect, 1985. 23. Jacobson A, Koehler JE, Jones-Brown C. The failure of routine assessment to detect histories of assault experienced by psychiatric patients. Hosp Community Psychiatry 1987; 38:

386-389. 24. Bell CC. Preventive strategies for dealing with violence among blacks. Community Mental Health J 1987; 23:217-228. 25. Kilpatrick DG, Best CL, Veronen U, et al. Mental health correlates of criminal victimization: A random community survey. J Consult Clin Psychol 1985; 53:866-873. 26. Bryer JB, Nelson BA, Miller JB, et al. Childhood sexual and physical abuse as factors in adult psychiatric illness. Am J Psychiatry 1987; 144:1426-1430. 27. Burgess AW, Hartman CR, McCormack A. Abused to abuser: Antecedents of socially deviant behaviors. Am J Psychiatry 1987; 144:1431-1436. 28. Green AH. Self-destructive behavior in battered children. Am J Psychiatry 1978; 135:579-582. 29. Rounsaville B, Weissman MM. Battered women: A medical problem requiring detection. Intl J Psychiatry in Medicine 1978; 8:191 -202.
