Health

Strategies:

• Health service response requires a system-wide approach that includes strengthening policies, protocols; upgrading infrastructure to ensure privacy and adequate supplies; training staff to ask about and respond appropriately to gender-based violence; provision of emotional support, free emergency medical treatment and preventive health care, and crisis intervention; assessment of a woman’s level of danger; documentation of cases; dealing with stigmatizing attitudes and practices; and utilizing referral networks. (Heise et al., 1999)

• Advancing laws, policies and protocols to provide comprehensive health care (including in sexual and reproductive health and HIV-related services, such as voluntary testing and counselling facilities and as part of primary care) and improve the quality and scope of services available to women and girl survivors of violence.

• Investment in equipment to complement efforts increasing survivors’ access to updated services (e.g. resources such as private rooms, free transportation, forensic and other examination equipment, medical supplies, rape kits and emergency treatments – emergency contraception, post-exposure prophylaxis for sexually transmitted infections and HIV, and safe abortion where it is legal), as well as targeted employment of trained and skilled service providers.

• Strengthening a quality response, whether through one-stop centres, integrated services within a facility or through coordinated referrals to other health facilities.

• Establishing standardized information systems in the health sector, across facilities to register and track cases, collect and analyze data.  At a minimum, the form of abuse and consequences should be recorded along with the woman’s age, among other demographic characteristics. (Morrison, et al., 2004)

• Institutionalizing health provider training (generally and for specialized services) and protocols to ensure standardized quality of care.

• Increasing the availability and accessibility of forensic exams, for example, by expanding the staff (e.g. authorizing and training nurse practitioners) that can perform these exams and by providing medical certificates free of charge.

• Improving monitoring and evaluation systems for ensuring quality health care services through participatory and systematic mechanisms involving women and girl users and community groups.

• Clinics and public-health community-based education (including HIV and AIDS and adolescent sexual and reproductive health interventions) should incorporate violence against women in programming, providing general information on the issue, raising-awareness on legal rights and availability of services. Multimedia approaches (e.g. skits, videos, songs, pamphlets, presentations, group discussions and workshops) are useful strategies to educate the community, especially women and girls, about services available and efforts to end violence against them.

• Data on violence against women and girls should be regularly collected and standardized into information systems as part of an institutional public health approach to addressing violence against women. (Morrison, et al., 2004)

• Research should be undertaken to understand the factors that influence access to services for adolescent girls who have experienced sexual abuse, such as the costs, negative or biased health provider attitudes, stigma from family and friends, among other factors, so that appropriate strategies for action and improved demand-driven service provision can be identified for this age group.

• In conflict-related situations, providers should follow the Minimal Initial Service Package for Reproductive Health in Crisis Situations, which establishes recommendations for the prevention of and support for cases of sexual violence in crisis situations.

Lessons Learned:

• Health providers are typically reluctant to ask women about experiences of violence - either from fear of offending women or reluctance to open up issues to which they will not know how to respond. Providers often feel they do not have the knowledge or skills to address violence against women. They may not recognize violence against women and girls as a public health problem or see it as their role to ask clients about violence or provide support for victims. They may therefore rarely identify violence as the reason for client visits in medical records. (Poverty Reduction and Economic Management Network/ World Bank, 2006)

• Providers’ beliefs regarding gender-based violence may also affect women’s access to meaningful care. Stigma and discrimination towards victims of gender-based violence in the community may be reflected in providers’ own attitudes and quality of response (i.e. if they consider the issue is a private matter which they should not become involved in).

• Serious gaps may also exist in the overall institutional response to gender-based violence. Service delivery and care is often fragmented and inconsistent across the health sector, especially in the absence of clear protocols to guide practitioners.

• Victims of sexual violence and rape face particular concerns and challenges when dealing with the health care system. Health care providers and counsellors may be unsure of how to deal with sexual violence cases and unclear on protocols that should be followed, including, for example, proper care and referrals for HIV and AIDs treatment and counseling, distribution of emergency contraception, and documentation of evidence for prosecutions.

• Training for health care providers should be part of broader interventions that cover pre-service and in-service training. Reforms should include protocols on service delivery, referral systems, the legal framework, and other relevant issues, such as professional development in the areas of medical, psychosocial and forensic responses. Single training sessions do not adequately equip providers to address the issue.

• Gender biases and attitudes of providers should be explicitly addressed in training programmes to prevent re-victimization or further trauma of survivors.

• Competencies of providers should be determined based on standards of good practice, the law and protocols in place. For example, providers conducting routine screening and counselling for survivors need a distinct set of skills from providers who only screen for violence and provide referrals to counsellors.

• Service providers should have the skills to respond to the multiple forms and diverse populations affected by violence (e.g. sexual violence against adolescent girls, or undocumented domestic workers, or survivors with multiple experiences of abuse) and provide tailored support to the survivors as needed.

• Interventions should be designed to target health providers who assist different groups of women (e.g. teen mothers, married and pregnant women, sex workers, employees in large enterprises, migrant workers, displaced women and girls).

• Survivors of violence should have access to medical treatment without having to first go to the police. Going to the police should always be the woman’s voluntary decision.

• Mandatory reporting of violence to the police or courts by service providers, although required in some legal systems, is not recommended because it violates women’s autonomy, decision-making and human rights. Mandatory reporting has been found to prevent women from seeking care, and reduce provider willingness to conduct screening, due to potential involvement in legal proceedings.

• Routine screening for violence should not be implemented without proper follow-up services and referral systems to protection, police and legal assistance in place.

• Forensic evidence should not be required in legal proceedings for cases of violence. However, doctors and nurses should be trained in forensics to improve their response to survivors and to make this evidence available if a survivor decides to seek legal recourse. (Morrison, et al., 2007)  Medical certificates should be granted free of charge.

• Health care services for survivors/victims of violence should be free and universal.

• The intersections between violence against women and HIV have often been neglected and require greater attention. In particular, counselling should be conducted with extra care to assess the risk of escalated violence for women who test HIV-positive and are in abusive situations.

• One-stop crisis centres provide a model of improved integrated services when adequately resourced and staffed; but they may be costly to implement and sustain and may be a more suitable strategy for urban centres or areas with high population densities.

For detailed guidance on working through the health sector, see the full module on this site.

Resources:

Responding to Intimate Partner Violence and Sexual Violence Against Women WHO Clinical and Policy Guidelines (WHO, 2013).  Available in English.

Final Report - Review of PAHO’s Project: Towards an Integrated Model of Care for Family Violence in Central America (Ellsberg and Arcas/PAHO, 2001).  Available in English.

Improving the Health Sector Response to Gender-Based Violence: A Resource Manual for Health Care Professionals in Developing Countries (Bott, Claramunt, Guedes and Guezmes/IPPF, 2004). Available in English and Spanish.

¡Basta! The Health Sector Addresses Gender-Based Violence and ¡Basta! Women Say No to Violence (IPPF/WHR, 2003).  Available in Spanish with English subtitles.

¡Ver y Atender! Guía Práctica para Conocer Cómo Funcionan los Servicios de Salud para Mujeres Víctimas y Sobrevivientes de Violencia Sexual (Troncoso, Billings, Ortiz and Suárez/Ipas, 2006). Available in Spanish.

A Manual for Integrating the Programmes and Services of HIV and Violence Against Women (Luciano/Development Connections, 2009).  Available in English and Spanish.

Addressing Gender-based Violence through USAID's Health Programs: A Guide for Health Sector Program Officers (Guedes/USAID, 2008).  Available in English, French and Spanish.

A Practical Approach to Gender-Based Violence (UNFPA, 2001). Available in English, French and Spanish.

VAW: the Health Sector Responds (PAHO, 2003).  Available in English and Spanish.

Guidelines for Medico-legal Care for Victims of Sexual Violence (WHO, 2003). Available in English.

Counselling Guidelines on Domestic Violence (CIDA/SAT, 2001).  Available in English.

Addressing Violence against Women and Girls in Sexual and Reproductive Health Services (UNFPA, 2010).  Available in English.

Gender-based Violence Training Modules: A Collection and Review of Existing Materials for Training Health Workers (Murphy, Mahoney, Ellsberg and Newman/Capacity Project, 2006).  Available in English.

Reducing HIV Stigma and Gender-based Violence Resources. Available in English.

Understanding and Challenging HIV Stigma: Toolkit for Action, Revised Edition (International Centre for Research on Women, 2007).  Available in English.