Role of Health Professionals & Health Facilities

1. RoleofHealthProfessionals & HealthFacilities

2. Medical Assistance • Health services are a lifeline for women whose contact with the outside world is restricted, because they sometimes are the only contact point with professionals who could recognize and intervene in the situation. • Studies show those affected by domestic violence seek treatment in various medical disciplines and care facilities. • However, most women do not disclose being victims of violence to health professionals even though they most often seek help from these professionals. • If the majority of health professionals do not ask about intimate partner violence most cases remain unnoticed (Bacchus et al. 2004a)

3. Medical Assistance • Virtually every woman uses the health care system at some point in her life - whether for routine health care, pregnancy and childbirth, illness, injury, or in the role of carer for children or older people. • Screening questions are helpful in asking about violence in intimate relationships and about violence against children. • All females aged 14 and older should be screened routinely for domestic violence by a health care provider who has been trained about the dynamics of domestic violence.

4. Medical Assistance • More women suffer from stress-related, long term health consequences of violent relationships; Fewer women visit first aid units/emergency rooms for injuries from acute violence. • The health care sector is in a unique position to help people suffering violence at home get the support they need. • Health services have a pivotal role to play in the identification, assessment and response to domestic violence. • In cases of high risk and when other protective services like shelters are missing, a hospital can even serve for protection by e.g. keeping the survivor stationary for some days until she has developed a safety strategy for the next weeks.

5. Medical Assistance • A woman’s health records can play an important part in bringing perpetrators to justice. They can also be an influencing factor in housing and immigration decisions. • The health professionals’ important task is to assure that the client’s experience is validated and to justify her feelings about the violence. • The professional’s role is to help the client acknowledge that there is violence in her life and to show that s/he believes the client’s story and what has happened to her.

6. Start by developing trust: A confidential relationship between the health professional and the woman makes it easier for her to open up and to talk about intimate aspects of her relationship. Use professional interpreters when needed (not the patient’s friend or family member). Take the initiative to ask about the violence: Do not wait for her to bring it up. Ask and listen to her experiences. It can happen that she is not willing to tell about the violence or may fear you would doubt it. 3. Ensure privacy: The victim’s and the child’s safety are paramount. Always ask about the violence when you are alone with the woman, do not ask when she is accompanied by her partner, sister, daughters, friends etc. Try to make sure that it is safe for the patient to return home. 4. Identify risk factors of intimate partner violence: For example, do not overlook disabled or old women. Disabled old women are at a greater risk of becoming a victim of violence. 10 Points Memory List of Intervention Steps

7. 5.Talk about legal protection options for victim and child(ren): Tell the victim that violence is always a crime. 6. Discuss beliefs related to violence with the victim: Give information on the facts: prevalence of violence against women; she is not guilty of, nor responsible for the violent behaviour; she cannot eliminate violence by changing herself or her behaviour; arguments and violence are two different things; an alcohol problem does neither explain nor justify violent behaviour. 7. Tell the victim about the impact of violence: Estimate victim’s needs for an immediate crisis or intervention visit at a psychologist or at a psychiatrist. Tell her about the impact of violence on victims (burnouts, etc). Motivate the client to seek psychological help. 8. Always document the interviewing process and tell the victim what you write down: Good documentation can be the most important evidence in case of conflict. Doctor’s statements, records from health care and other professionals, messages on answering machines, SMS, e-mails, letters, the victims’ diary etc. can be used as an evidence. 10 Points Memory List of Intervention Steps

8. 10 Points Memory List of Intervention Steps 9. Tell the victim about further appropriate services: Tell her about services available which can offer support and assistance. Be aware of services in your region. Give the woman information on local and national support agencies and helplines. You can also make an appointment for her at one of the services. 10. Don’t ever leave the patient alone: Meet her again, if there is no available service at that moment. Source:Perttu, S. Kaselitz, V. (2006): AddressingIntimate Partner Violence. GuidelinesforHealthProfessionals in Maternityand Child Health Care).

9. Elements of Improvement • Screen for domestic violence victims. • Assess the health impact of their victimization. • Conduct intervention by giving the victim validating messages, e.g.: • “I am concerned about your safety and well being.” • “You do not deserve abuse.” • “You are not alone.” • “There are options and resources available.” • “Domestic violence is complicated, takes time to deal with, and I want to be helpful.” • Providing information about domestic violence • Assisting in safety planning • Referring the victim to appropriate support and advocacy services • Conducting a follow-up • Documenttheviolence Source: FUND Manual for Health Care Providers

10. Assisting Victims is More Cost Efficient • Treating the injuries or other obvious medical consequences of domestic violence without responding to the cause of the problem often results in inadequate care. • Victims continue to be injured; • they continue to require more and more medical interventions; • their health deteriorates; • and health care costs increase. • To provide appropriate care to domestic violence victims, health care providers must be able to identify, assess, and intervene in culturally appropriate ways that directly address both the problem of domestic violence and its immediate health consequences.

11. Exercise: Barriers and Improvementsto Medical Care of Professionals From the Viewpoint of the Health Care Providers & From the Viewpoint of the Survivors of Violence.

12. Barrierstomedicalcareby Health Care Providers • Lack of knowledge about competent handling of the violence issue and lack of appropriate skills for counselling female patients affected by violence. As different studies show there is a fear of "opening Pandora's Box" (McCauley/Yourk et al. 1998). Health specialists often don't know which steps to take when they learn that a woman is affected by violence. They lack information on existing support services and how these work and are often lacking the appropriate professional contacts. • Insufficient knowledge about causes, consequences and dynamics of domestic violence, and of the situation and demands by women affected by violence. Furthermore, stereotypes and misinformation let health specialists set unrealistic goals for women affected by violence, and for their own support role.

13. Barrierstomedicalcare • Lack of time for medical care as well as inadequate funding of counselling. Even though in some studies these aspects seem to be of secondary importance, in combination with deficits in competence and knowledge they are an additional obstacle to doctors' and nurses' readiness to talk. Professionals often cannot estimate how time-consuming a conversation would be and are worried about having to cut back on the time needed for other patients. • Missing intra- institutional support such as standardised protocols for dealing with victims of domestic violence. Uncertainties about employment law and confidentiality rules are widespread. As experiences with intervention projects in medical facilities show, individual and institutional barriers can be overcome. The fact that violence is rarely made an issue in the treatment context is largely due to health specialists not being trained to face the violence issue. Up to now interpersonal violence has not been a part of the curricula in nursing training and medical schools.

14. Barriersfacedbyfemalepatients •  Shame, guilt, and the feeling to be solely or partly responsible for the violence suffered. The woman may be convinced that it is her mistake and that she can stop her partner's mistreatment of her if she carries out his wishes and "betters" herself. • Fear of negative responses and fear of being blamed for not separating from the abusive partner. Not knowing which steps professionals in the care facility will take, whether police will be informed, whether the perpetrator will be approached. • Fear of an escalation of violence and of further threats, as violent partners usually forbid women to talk about the violence with any other person and threaten with further violence should they be disobeyed.

15. Barriersfacedbyfemalepatients • Social isolation and the feeling of having to deal with the experienced violence all by themselves. • Long-term experiences of complex mistreatment and damage women's selfconfidence and self-esteem to such an extent that the search for, and the acceptance of help and support becomes difficult (Dutton 2002). • Situational aspects of the counselling and treatment situation: The majority of the interviewed female patients react sensitively to the physical conditions of the facility, the counselling atmosphere and the behaviour of doctors and nursing staff. (See also: Handout Role of Healthcare) Sources: FUND (1998): Improving the health care response to domestic violence – a trainer’s manual for health care providers, Manual.WAVE (2009): PRO TRAIN Improving multi-professional and health care training in Europe – Building in good practice in violence prevention, Manual.

16. Confidentiality vs. mandatoryreporting • It is vitally important that information on gender-based violence is kept confidential. • But it’s important to understand that there are limits to confidentiality. (ex.: children are at risk; if records are being used as evidence in a court case; for advocacy). Conclusion: The only acceptable reason for sharing information is to increase a woman’s safety and that of her children. Even then, only relevant information should be shared.

17. Medico-legal aspects of sexual violence • Exposure to sexual violence is associated with a range of health consequences for the survivor: physical injuries; pregnancy; STIs, HIV and hepatitis B; counseling and social support; and follow-up consultations. The WHO provides standards for clinical management and dosing regimes for the following health issues: • physical injuries • pregnancy prevention and management • emergency contraception • sexually transmitted infections (STI)- testing- prophylactic treatment for STIs • HIV/AIDS - testing - post-exposure prophylaxis Source: adapted from WHO (2003) Guidelines for medico-legal care for victims of sexual violence.

18. Medico-legal aspects of sexual violence • Hepatitis B • patientinformation • follow-upcare • medicalreview • follow-upvisits (at 2 weeks, 3 months and 6 months post assault) • Referrals Source: adaptedfrom: WHO (2003): Guidelines for medico-legal care of victims of sexual violence, Manual, Geneva.