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This is a true story.
Katie sits in a Chevy pickup truck, parked in the gravel lot of a bar. It's a Thursday afternoon in the early 1960s, and she's ten years old. She's been waiting for two hours now, imagining she's "Kitten" from Father Knows Best.
Her father, a stout man, stumbles out of the bar and struggles into the truck. He doesn't speak or look at her. He cranks up the engine and drives off, heading to their farm. Just before 6:30, he pulls into the driveway, and Katie bolts from the truck and scampers into the house. Her father heads off to another bar.
After dinner with her mother, Katie plops down on the couch in the living room. As she watches television, her father comes home. He passes the living room without a word and heads for the master bedroom, where her mother's getting ready for bed. When he shuts the bedroom door, Katie hears them start to argue. As their voices rise, she grabs her Bible, turns up the volume on the TV, and sits in a corner. This is her weekly routine. With her knees tucked under her chin and the Bible lying open on the floor, Katie uses her fingers to follow the scripture. She reads fast, trying to crowd out the sound of them, louder and louder. Katie hears the slap of leather belt, the punch of fist, the wail of her mother. Katie silently prays, "Please get it over with."
The sounds from the bedroom stop. The bedroom door slings open. Her father catches a glimpse of Katie in the corner. He stumbles toward her, yanks the Bible away, and, like a brimstone preacher, jabs it in the air. "I don't know why you think this is going to save you," he hollers. He slings the Bible across the room and knocks a painting off the wall. He pulls the half-looped leather belt from his jeans as Katie wraps her arms around her legs and crouches lower on the floor. He whips the belt at her, striking parts of the wall very close to her head, and walks away. Katie stays in the corner, balled up and shaking.
The noises resume. Katie closes her eyes and prays again. She hears the faint beg of her mother, "Please don't." But her wails grow louder with every slap. "He's hurting her real bad," Katie thinks. Louder cries. Then her silence.
Katie gets up, wipes the tears from her face, and walks into the kitchen. She grabs a broom. She creeps down the hallway. She opens her parents' bedroom door. Her mother, half-naked, lies on the bed. Streams of blood drip from her mother's mouth, and the colors of maroon and black and blue stain her face. "She's dead," Katie thinks. "He's finally killed her."
He stands over her mother with unzipped jeans and a clenched fist. Katie grips the broom, and with all her might, she swings and knocks him in the back of the head. She swings again and again until he turns around, grabs her arm, and twists the broom from her hand. He stares Katie in the eyes, and she stares back. He slams the broom to the floor and walks out of the house.
Katie rushes to her mother. She wipes the blood from her mother's face and buttons her nightshirt.
They won't call the police. They won't go to the doctor.
Late into the night, her father comes home and falls asleep beside her mother. Katie stays awake much of the night, daydreaming once again that she's "Kitten," living in a house that she can call a home, where she learns to love, where she goes to heal, and where she finds security.
And today, every so often, Katie, now a fifty-year-old mother of two, lies awake at night, struggling to fall asleep as she finds herself caught up in her childhood dream as "Kitten." She remembers a saying from a movie: "Childhood is what we spend the rest of our lives trying to overcome."
"I guess that's what I'm doing," Katie says.
A blindness in society
Researchers across the Carolina campus have heard their share of stories similar to Katie's as they work to understand and reduce the prevalence of family violence — the physical, sexual, and emotional abuse family members and intimate partners inflict on each other. There are stories of a three-year-old with a case of gonorrhea, a mother who drowns her infant son in a washing machine, the husband who stuffs his wife alive into an oversized safety-deposit box, and the older brother who rapes his eight-year-old sister.
How many stories of family violence are out there?
According to the UNC Hospitals Beacon Child and Family Program, which provides services to victims of family violence, about 30 percent of all adults and about half of all women in North Carolina have been physically abused by a partner at some point in their lifetimes. About 25 percent of women and 15 percent of men experience some degree of sexual abuse as children. And, about 80 percent of the perpetrators are people the victims know.
"But this is just the tip of the iceberg," says Carol Runyan, professor of health behavior and health education and director of the Injury Prevention Research Center. "Statistics don't capture all the real cases, and we don't know how big the iceberg is."
Many cases go unreported, researchers say. For instance, the National Women's Study, a large epidemiological research project conducted by the National Institute on Drug Abuse, found that 84 percent of the more than three hundred-thousand women raped each year in the nation do not report their rapes to the police.
But not only can it be difficult to track nonfatal assaults, it can also be difficult to track fatal assaults, says Marcia Herman-Giddens, adjunct professor of maternal and child health and senior fellow at the North Carolina Child Advocacy Institute.
Just consider there's no official state data-collection system in North Carolina that tracks cases of all abuse-related homicides.
"If you wanted to know how many people died from pneumonia or AIDS last year, you could go to the North Carolina vital records to get the numbers," Herman-Giddens says. "But what people don't realize is that you can't do that with abuse homicides. There isn't a [tracking] code that exists for all cases of abuse."
The North Carolina Coalition Against Domestic Violence (NCCADV), a nonprofit organization that provides training and services to agencies that serve victims of family violence, for example, tracks homicide data by collecting information about abuse homicides published in local newspapers across the state and by receiving unofficial reports from local domestic-violence programs. As of November 11, 2004, NCCADV reported sixty-five domestic-violence-related murders in North Carolina in 2004.
"This isn't a scientifically sound list," says Mary Beth Loucks-Sorrell, executive director of the NCCADV, "but it's better than no information at all."
And if you look at just the data about child-abuse fatalities available from the state's vital records, you will miss two-thirds of the thirty or so homicides that occur each year in North Carolina, says Herman-Giddens, who looked at medical examiners' records and police reports to gather child-abuse homicide statistics in North Carolina between 1985 and 1999. Granted, child-abuse homicides represent the most severe cases of abuse. But if we're missing cases of abuse after children are dead, how many cases are we missing when they're alive?
This lack of accurate data on homicide deaths, Herman-Giddens says, reflects "a blindness in society."
"We don't want to own up to the enormous problem of family violence," she says.
Cobwebs on the inside
Today Mary, Katie's mother, stands in the driveway of her house on a cloudy day in the same small town where she raised her daughter. Mary, seventy-eight, is several weeks removed from having surgery on her back. The doctor has instructed her to stay off her feet. But every day, as weather permits, Mary begins her day by walking outside of her house with a cane in one hand and a tool to pick up pinecones and sweet gum balls in the other. "If you keep the outside looking nice," she says, "nobody's gonna look for the cobwebs on the inside."
And for twenty-five years, throughout the first half of her marriage, Mary says, she hid "the cobwebs" by wearing long-sleeve shirts, turtlenecks, and heavy makeup. She often called in to work sick and canceled nights out with the girls. And nobody, Mary says — not her parents, her brothers and sisters, her coworkers, her doctor, her friends, her minister — nobody ever said a word to her about her husband's abuse.
Until the women's movement brought domestic violence into the legal lexicon in the 1960s and '70s, the public largely shielded itself from what went on inside homes, researchers say.
The first intimate-partner-violence program to provide intervention for people in abusive relationships in North Carolina opened in 1978. The next year North Carolina adopted the Domestic Violence Act, which protects men, women, and children.
According to data from the N.C. Council for Women/Domestic Violence Commission, between 2002 and 2003 the eighty or so public domestic-violence programs in North Carolina answered 90,341 calls from women and men who were in abusive relationships. More than half of the callers entered counseling, and over 12,000 adults and children stayed in a shelter for some period of time.
The North Carolina Department of Health and Human Services receives even more calls of concern about children suspected of being abused and neglected. North Carolina law requires everybody, including teachers, doctors, parents, and neighbors, to report suspected cases of child abuse and neglect to child protective services.
According to the "North Carolina Child Protective Services Data Card" study, published in 2004 and led by Herman-Giddens using data from the North Carolina Division of Social Services, child protective services (CPS) received 136,516 calls of concern between 2001 and 2002.
Statewide, 21 percent of the calls of concern were screened out and never investigated. In North Carolina — one of thirteen states in the United States to run its CPS office county-by-county — the number of calls counties screen out ranges from 3 percent in Pasquotank to 47 percent in Davie.
"Even though there are some legitimate reasons to screen certain calls," Herman-Giddens says, "there's something telling when you look at the data and see that one county screens out ten percent of the calls and another county screens out half of them."
Part of the discrepancies may be due to the wording of the North Carolina statute guarding children from abuse, Herman-Giddens says. The law defines child abuse "as a parent, guardian, custodian, or caretaker" inflicting a "serious, nonaccidental injury" on a child. But the law doesn't define serious injury, leaving open the opportunity for varied interpretations of what's considered to be serious, Herman-Giddens says. So each county operates its social service agencies differently, like separate businesses, she says, even though the state provides protocols, training, and guidance to counties.
According to the data-card study, less than 8 percent of all reports investigated for neglect or abuse are substantiated for physical and sexual abuse — the lowest proportion in the United States.
Desmond Runyan, professor of medicine at Carolina and medical director of the Center for Child and Family Health, says it can be difficult to prove cases of abuse.
The center, a collaborative effort among UNC-Chapel Hill, Duke University, and N.C. Central University, provides medical examinations, mental health therapy, and legal services for children and teenagers who have been abused. The center reviews over six hundred cases each year. Ninety-five percent of the children and teens brought in are examined for sexual abuse, Runyan says.
But medical evaluations provide physical findings in only 5 percent of the sexual abuse cases, Runyan says, because most of the abuse does not leave a physical trace.
Also, many children are too young to verify abuse. And if a child is old enough to verify the sexual abuse, parents are not always supportive. Runyan says one-third of mothers do not support their children's version of events, even in cases where there are physical findings of abuse, especially if the perpetrator is the mother's boyfriend or husband. Runyan once had a mother tell him, "My daughter's the other woman trying to take my man." The daughter was eleven years old.
Of the cases the center handles, 10 percent head to court, and another 40 percent result in the perpetrator plea-bargaining. The other half of the cases never result in any charges being filed. Herman-Giddens adds that, in her study of the legal outcomes of child-abuse homicides from 1985 through 1994, one-third of the suspected perpetrators in child-abuse homicides cases were never charged.
These outcomes for child-abuse allegations are similar to the outcomes of intimate-partner-violence cases. According to a Raleigh News & Observer series published in May 2003, about 238,000 misdemeanor domestic-violence charges were filed between January 1997 and October 2002. One-third of the domestic-violence cases ended in a conviction, and 53 percent of the charges were dismissed, either because the victim did not show up in court, the victim requested the charges to be dropped, or there were no physical findings of abuse.
"We may never see a major reduction in the number of children that come to the attention of child-welfare services," says Richard Barth, professor of social work. "The definitions of child abuse, and even domestic-violence laws, keep changing."
Across the nation, for example, child protective services continue to receive more and more calls of concern about children who are excessively obese and who have been exposed to methamphetamines. And when North Carolina strengthened its domestic-violence laws this past summer — making strangulation a felony and increasing state funding for domestic-violence programs — one provision considered but not passed was requiring parents who exposed their children to intimate-partner violence be reported to child protective services in all incidents. Minnesota passed such legislation several years ago, Barth says, but backed off after about nine months because the number of calls exceeded the ability of child protective services to respond.
North Carolina "understood what happened in Minnesota and developed a more nuanced and manageable approach to responding to domestic violence," Barth says.
"Hopefully, we will just keep raising the expectations for how to safely raise children, and broaden our work with other agencies that help deal with serious family problems," he adds.
"I didn't know how to love."
Katie sits in the corner of her darkened bedroom, in a ball, with tears streaming down her face. It's the late 1970s, and her son, who's of preschool age, plays on the bed. She's been in the corner for three hours and has not left the house for several days. Her husband arrives home from work. He turns on the light and opens the blinds. He pulls a quarter from his pocket, throws it on the bed, and points at it. "There," he says, "that's all you're worth." He grabs her son and walks out of the house. She remains in the corner and continues to cry. Her husband returns home an hour later. "You're such a terrible mother," he says. "You'll get better or I'll leave."
"I was a terrible mother and a terrible wife," Katie says today. "I didn't know how to love."
Women who have been assaulted by their partners miss more days of work, experience more depression, and suffer lower self-esteem than other women, says Sandra Martin, professor of maternal and child health and a faculty member at the Injury Prevention Research Center. They're more likely to drink alcohol and use illegal drugs, Martin says, based upon a questionnaire she administered to women in an ob/gyn clinic.
And children who have been abused have a far greater risk of being developmentally delayed, doing poorly in school, engaging in delinquent and promiscuous behavior, abusing alcohol and drugs, and exhibiting violent behavior, Desmond Runyan says. Many abused children lose their sense of trust in people. They develop feelings of vulnerability, helplessness, and lack of control. They see the world as a threatening and potentially harmful place.
"It colors your whole world," adds Douglas Drossman, professor of medicine and a gastroenterologist.
The psychological effects of abuse are well known. Over the last fifteen years, Drossman and Jane Leserman, professor of psychiatry, have worked to provide insight into how abuse affects our bodies.
Their research, some of the earliest to examine the effects of sexual and physical abuse on health status, began when a twelve-year-old patient, referred to as A.L. in the case studies, walked into Carolina's Center for Functional GI & Motility Disorders with her mother in 1986. From the time A.L. was seven years old, she had experienced irritable bowel syndrome, including lower abdominal pain and severe constipation that resulted in occasional nausea and vomiting. For the next several years, A.L. visited Drossman in the gastrointestinal (GI) clinic for checkups as her condition gradually improved.
On a visit in 1989, A.L.'s mother walked into the clinic to inform Drossman that A.L., then sixteen, was dating a nineteen-year-old. Later that day Drossman asked A.L. if she'd been sexually active with her boyfriend. She had. Drossman suggested they schedule an appointment for a pelvic exam to weigh birth-control options.
A month later she returned for the pelvic exam, but she had lost four pounds, she had quit the high-school cheerleading squad, her grades had fallen, and her bowel symptoms had worsened. A.L. disclosed to Drossman that on the same day he suggested she have a pelvic exam, she began having nightmares. The nightmares led to her recollection of being sexually abused by a family friend when she was between the ages of three and seven.
Over the next several visits to the GI clinic, A.L. discussed her abuse history with a therapist. By 1991, her visits to the GI clinic were no longer necessary.
Because of A.L., Drossman says, he became "fascinated with the idea that abuse is a hidden issue that may be affecting chronic and unexplained GI symptoms."
Drossman and Leserman organized a study to interview patients about their abuse history in the GI clinic. And they found that more than half of the 239 women in the GI clinic had been either sexually or physically abused. Leserman later worked with gynecologists at Carolina to discover that nearly half of the women in the pelvic pain clinic reported they had been either physically or sexually assaulted, as well.
Drossman and Leserman also discovered that women who had been raped reported more abdominal pain, more headaches, more somatic symptoms (or physical symptoms that occur at times of stress), more pelvic pain, and poorer quality of life. They also spent more days in bed and had more lifetime surgeries.
The researchers also followed this group of patients in the GI clinic for over a year and found that those patients with more severe abuse have, on average, eight more doctor visits than those who do not report being abused. These abused patients have more chronic problems that aren't treated, and they rarely tell their doctors about their history of abuse.
"The longer the duration and the more invasive the abuse, the greater the health effects are," Leserman says.
Even when controlling for other traumas such as the death of a parent or childhood neglect, Leserman says, severe abuse — especially sexual abuse — remains a significant predictor of poor health. The long list of health outcomes includes panic-related symptoms such as shortness of breath and difficulty sleeping, fatigue, muscle pain, painful intercourse, headaches, gastrointestinal symptoms such as constipation and diarrhea, and a greater risk for obesity and eating disorders.
"Though some of these are common problems that we all may experience at some point in our lives," Leserman says, "you see more frequent pain and dysfunction in people who have been abused."
But why does abuse affect our health?
Drossman has an idea.
If you sprain your ankle playing basketball, he says, you might continue to play without noticing the pain because the brain releases endorphins, a natural chemical that functions as a pain reliever. Drossman hypothesizes that the brain doesn't work as well in filtering pain in people who have been physically or sexually abused.
And they found this to be the case in A.L., who returned to Drossman in 2000, when her bowel symptoms returned. At the time, she'd been married for about three years to a man who sexually and emotionally abused her.
A functional MRI scan of A.L.'s brain activity measured during painful stimuli showed greater activation in the region of the brain — anterior cingulate cortex — that regulates pain. "She had an increased sensitivity to pain," Drossman explains.
Several weeks after the brain-imaging study, A.L. began divorce proceedings. Her problems of lower abdominal pain and diarrhea gradually vanished. In April of 2002, A.L. agreed to a second brain-imaging study. This scan showed a higher threshold to pain and a reduction of activation in the cingulate cortex.
Though this is just one case study, Drossman and Leserman say, other studies have shown that patients with abuse history and post-traumatic stress disorder (PTSD) have greater activation in the anterior cingulate cortex and the medial prefrontal cortex, which regulates emotions and memories, when they hear emotional words, such as rape or mutilate, than people who do not have an abuse history or PTSD. Research by Vincent Felitti, who is a fellow with the Kaiser-Permanente Medical Care Program, also shows that other major illnesses such as cancer, chronic lung disease, and heart disease are related to childhood trauma. His series of studies suggests that people who have more trauma adopt more behavioral risk factors such as alcoholism, poor diet, smoking, and lack of exercise, which influences the development of poor health.
Drossman, Leserman, and Yehuda Ringel, assistant professor of medicine, also have led efforts to scan the brains of an additional forty GI patients, some with an abuse history and some without, to measure brain activity during painful stimuli. The researchers are currently analyzing the data.
Women with abuse history, Leserman says, may have a lower tolerance for pain, or "there may be changes occurring at the level of the brain that causes physiological dysregulation. We're not certain what exactly explains these poor health outcomes," she says. "We're just beginning to scratch the surface of this research.
"But the bottom line — if you look at people who were abused thirty years ago, many are looking just as bad as those who were abused last year," Leserman says.
"Why did you do this to us?"
Every so often, Mary says, when the memories of the terror catch up with her, she walks into her bedroom. She picks up a photo of her husband taken in 1999, on the day of her fiftieth wedding anniversary. She stares her husband, who died in 2001, in the eyes. And as if he's standing in the room with her, she wonders out loud: "Why did you do this to us? And why did I let you?" She places the photo back on the dresser, face down. Several weeks will go by before she'll return the photo to its upright position. "I don't know why he did what he did. He was a complex man," she says. "Me. Why did I stay? You just spend so much time trying to survive, you don't think about leaving."
A common assumption is that children who grow up in violent homes are the ones who use violence as adults. And though it's true, Desmond Runyan says, that children who grow up in violent homes are thirty times more likely to use violence, this generation-to-generation cycle of violence only accounts for about 20 percent of the cases of abuse, he says, based upon results from a study conducted by pediatrician Frank Loda at Carolina in the 1970s and confirmed in more recent work. "This doesn't explain the other eighty percent of the cases. Most kids who grow up in an abusive home do not grow up to be abusive," Runyan says.
A range of factors, including alcohol, substance abuse, and mental instability, has been cited to explain cases of abuse. But underlying these factors is a common thread — stress.
Particularly in regard to physical abuse, the most prominent factor appears to be additional stress most often caused by financial strain, Runyan says.
Results from a Gallup study conducted by Runyan and colleagues in 1995 reveal that children from the lowest socioeconomic group are at three times higher risk for abuse than those in the most affluent group. Children of single mothers are seven times more likely to be victimized than children from two-parent homes, Runyan says. And children from military families are also more vulnerable, Herman-Giddens adds.
Herman-Giddens, using medical examiners' and police reports from North Carolina, found that children from military families had a child-abuse death rate twice as high as civilian families between 1985 and 2000. Thirty-five of the 378 child-abuse homicide deaths during that period occurred in Cumberland and Onslow counties — home to the state's largest military installations. The U.S. Department of Defense reports there were twenty-six child-abuse homicides during the same period among military families.
An Injury Prevention Research Center study, coauthored by Desmond Runyan, also found that children from military families in North Carolina had a traumatic brain injury rate five times higher than children in civilian families between 2000 and 2001.
Why military families have a greater rate of child-abuse deaths and traumatic brain injury has not been widely studied, Herman-Giddens says. Speculation abounds that a contributing factor could be that soldiers are trained to overcome "the normal tendency to not kill people and exist in a milieu of violence," she says. But, Herman-Giddens believes, a greater factor of violence in military families is the same factor confronting civilian families — "unbelievable stress."
"Any additional stress can trigger abuse," Desmond Runyan adds. This can include job loss, difficulty in paying the bills, death of a parent, social isolation, or natural disasters.
For instance, families were more vulnerable to abuse after Hurricane Floyd, which caused severe flooding in eastern North Carolina in September of 1999, a study coauthored by Runyan found. Brain injuries in children caused by child abuse were five times more common in the hardest-hit counties in the six months after Hurricane Floyd than before. The rate of brain injuries returned to normal levels after six months, Runyan says.
In Sampson County, one of the hardest-hit counties by Hurricane Floyd, intimate-partner-violence rates jumped nearly 40 percent in the year after the hurricane hit, reports Pamela York-Frasier, professor of family medicine.
"But stress does not fully explain all cases of abuse," Herman-Giddens says, "because most parents under stress do not hurt their children."
And though it's certainly more difficult to parent without a job, heat, electricity, or a source of food, many families who struggle with poverty do not abuse their children, Barth adds. The abusers, he says, don't know how to cope with stress; they lack the parenting skills to create safe environments for their children.
"If you grow up in an environment of harsh or severe parenting and where there are other factors in the parents' lifestyle, such as domestic violence, poverty, and substance abuse, and these things become accepted as normal," Barth says, "it's likely that's all going to go into the pot and boil up in another case of abuse."
Julia Wood, professor of communication studies, draws a similar conclusion about the inability of abusers to cope with stress based upon her interviews with twenty-two men who were incarcerated in the Albemarle Correctional Institute, in Badin, N.C., in 2001. All the men admitted to abusing or killing their female partners.
"We all have some degree of stress, and that doesn't mean we all go out and hit someone," Wood says. "But these men have never been taught how to deal with stress and think through their options before they react."
Watch children on a playground, she says. Kids are full of impulse, and they often don't think before they act. But most of us, she says, had the privilege of growing up with parents who stopped us before we jumped off the top of the monkey bars. Some of us, though, don't grow up with parents who say, "Let's stop and think about this for a minute."
"I didn't believe that thinking through options was a skill," Wood says. "But, by golly, it is."
Environmental conditioning, or their upbringing, also influenced the way the men defined manhood, Wood says. They thought they had a right to control their partners. "A woman's kind of like a dog," a man told her. "You got to break 'em. A dog don't do right, you beat it 'til it do what you say."
Some of the men didn't feel they measured up to a cultural definition of manhood as a breadwinner, she says. "I couldn't get a decent job," another man told her. "I didn't feel like I could take, uh, like I was the provider, you know what I'm saying? I didn't feel like a man."
Some men, Wood says, rationalized the abuse. "It was kind of like once she came back, it was kind of like, in my mind, she accepted it," a man said. "So now I can view this as acceptable behavior. It's okay for me to do it."
Researchers at Carolina also have tried to understand how women, who are the victims in 95 percent of intimate-partner-violence cases, become involved in abusive relationships.
Studies by Sandra Martin show that women in abusive relationships are more likely to be unmarried and young with no more than a high-school education. Other studies show that the higher the income of women, the less likely they are to be in abusive relationships. And the higher the income rises for women in abusive relationships, the more likely they are to leave.
Wood also interviewed twenty women who were involved in abusive relationships. She's heard from women with low self-esteem: "I felt like I wasn't worthy of anything."
From women who didn't believe they had another option: "In high school, we didn't talk about it because it was just part of the relationships. It wasn't, like, a problem."
From women who feel trapped: "When you're in it, you don't, you can't see above the swirling of what's happening around you."
From women who feel obligated: "I lost my virginity to him. I equated sexual relationships with marriage, so now I'm going to have to marry this guy."
From women who believe in the promises of love: "There were things I didn't question even when he hit me. He was my soul mate. I felt so complete with him."
And from women who blame themselves: "I never, ever thought to blame him. I was, like, maybe I did something wrong, maybe I shouldn't have said that, maybe I just need to be quiet."
After Wood completed the interviews, she says, she reflected on the interviewees' comments and on her life. "I've never been in an abusive relationship," Wood says. "And I hope if I ever were in one, I would walk away. But I don't know. What became clear through the interviews was that some of them — the men and women — are just like you and me."
"You can't ever lose hope."
Mary sits on a couch beside a male coworker at a company party. It's a Friday evening in the early 1980s, and her husband stands at the corner of the bar and drinks beer after beer. His eyes fill with fury when he catches Mary talking to the coworker. He slams a beer can down and hollers through an audience of about thirty, "Get away from my wife!" He slurs obscenities as he pushes his way to Mary. He grabs her arm and grips her wrist. "You slut!" he yells. She breaks free and makes her way past the silent crowd. Her husband follows. She hurriedly opens the exit door. He kicks her in the back and knocks her to the ground. "You're not going anywhere without me," he yells. He pulls her to her feet and wrestles her to the truck.
Mary returns to work on Monday under a façade of makeup. There are several awkward exchanges with coworkers but no mention of the incident. That night Mary tells her husband she'll leave him if he doesn't stop drinking. He listens. And after twenty-five years of marriage, he'll never drink again. He'll never hit again. A month later Katie's seven-year marriage ends. Katie, with her two young children, moves in with her parents.
"Thank God he quit drinking when he did," Mary says today. "I guess you can't ever lose hope. I finally found the strength to say enough is enough...There was nothing left to hide anymore."
Desmond Runyan's voice carries a message of hope as he walks through the Center for Child and Family Health, surrounded by several children, including a three- and a four-year-old, who have been referred to the clinic by child protective services for suspected cases of sexual abuse.
"Children who have been abused are not the walking wounded. They're resilient," he says. "Just because something bad happens to you, that doesn't mean your life is over."
Results from a Carolina study published in 1989 show that the recovery of children depends on their relationships with their mothers.
"It's less important what the child's relationship with the abuser is," Desmond Runyan says. "Maternal support is the single best predictor of how a child will cope with abuse."
It also helps, the researchers say, for children and adults of abuse to talk about their experiences with a therapist. And most people, Drossman says, want to talk about their history of abuse. Of the more than two hundred women interviewed as part of Drossman's and Leserman's study in Carolina's GI clinic, Drossman says, only two of the women had "negative reactions" to being questioned about abuse. Most people, he says, want to be heard.
But they can't be heard, he says, if they're not asked. In a survey of doctors in the GI clinic conducted in the 1990s by Drossman and Leserman, more than 80 percent of the doctors did not know about the abuse history of their patients.
"We need to create an environment where doctors have the type of support where patients feel comfortable enough to disclose information," Drossman says. "Before the 1980s, we weren't asking patients about sexual preferences, but now that's a standard question because of HIV.
"It's also a matter of opportunity to ask about abuse."
Family-violence programs also must become more focused on preventing violence, says Carol Runyan of the Injury Prevention Research Center. The majority of services exist to help them deal with abuse after the crisis, she says.
"Those services are important, and we should keep providing programs to deal with crises," she says. "But we ultimately would like to stop the problem before it starts. We'll never prevent all violence, but it would be nice if we could get to the point where we need only half of them.
"We have to recognize that family violence is preventable and it doesn't have to happen," she says.
In October 2003, the Injury Prevention Research Center launched PREVENT (Preventing Violence through Education, Networking, and Technical Assistance), a training program for practitioners who work with victims and perpetrators of family violence. The goal of PREVENT is to help practitioners work to change the environment of homes where there is violence.
Martin and Stephen Marshall, from the Injury Prevention Research Center, also are helping the North Carolina Department of Health and Human Services develop its part of a thirteen-state effort to establish a National Violent Death Reporting System. The system will pull together data about violence from medical examiners, police, crime labs, and coroners to help gather accurate data and establish a standard for identifying abuse-related deaths.
"Once you have the data, it turns the invisible into the visible," Herman-Giddens says. "Once it's visible, the problem of family violence must be addressed."
Even over the past decade, there's been increased attention to the issue of family violence as Congress passed the Violence Against Women Act of 1994. And several high-profile cases such as that of Hedda Bussbaum, who witnessed the killing of her six-year-old daughter after the killer — the father — had beaten her, have generated public discussion.
Between 1993 and 2001, the rate of intimate-partner violence declined by nearly half, according to a U.S. Department of Justice report released in February 2003. In 1993, 10 percent of females reported having experienced intimate-partner violence during the past year. In 2001, the percentage dropped to five.
"A good economy helps steers all ships. There's also been changes in laws and the recognition of domestic violence as a serious concern," Desmond Runyan says of the decline in intimate-partner violence. "This was the best news we could have hoped for, for the health of our kids." Where there's intimate-partner violence, he says, there's four times greater risk for child abuse if children live in the home.
"And look at all the progress we've made just in the last hundred years," he adds.
Consider over two thousand years ago, when children were killed for being born with a deformity and when kids were sent off to war. The Bible is full of examples of our violent past, he says. Now we have child labor laws, universal schooling, and domestic-violence legislation.
"When you consider the whole history of the world, a sustained focus on the well-being of children is a recent development in the civilization of humans," he says. "But it's not fast enough for those who suffer at the hands of others."
"You will survive."
Today, on a cloudy day in October, Katie, petite and slender, stands in the bedroom of her house. She picks up a framed, black-and-white photo of herself taken in 1957, when she's three years old. Her thin fingers trace the image of herself as a little girl standing alone in front of a set of steps leading to a house. In the photo, a slight pout graces her baby-doll face. She looks like her favorite stuffed animal's gone missing. Katie doesn't know where the photo was taken or its context. But every day she catches a glimpse of the photo, one of three she possesses of her childhood. In the photo, she says, she sees a "sense of longing."
"You long for a family like the one you think everybody else has," she says. "You long for a home."
With the photo in her hand, Katie sits down in a chair. She looks out the window beside her, past the gardenias in her yard, and toward the house where her mother lives. She speaks of the memories — the day her father poured gasoline around the house, lit a match, and set the house on fire with her in it; the nights her mother woke her to chase her father down at a bar; and all the chocolate meringue pies her mother made for her after the nights of horror.
She turns her head from her mother's house and glances back at the photo of the past, and a slight smile highlights her face. "The past is done," she says. "It's over with. But you can't move on because the past is a part of you. It's who you are. And all you can do is believe that things will get better; and eventually, they will.
"You will survive," she says. "You have no choice but to." She returns the photo to her nightstand, leans back, and squints her eyes to stare at the photo from afar.
"I'm livin' my dream now," she says. "I've followed my calling into teaching. I raised two children who turned out okay. And, I have a home. I finally have a place where I can go to to find security, and where the memories of a haunted childhood can be put to rest."
