Domestic violence and the health sector, an international perspective Dr Henrica A. F. M. Jansen International Conference Joint Approach to Family Violence: Legislation, Indicators, Enforcement May 20-21, 2009, Bishkek

To whom do woman talk about physical partner violence? % 1.Many women never tell anyone about partner violence 2.Very few women talk to a formal agency or person in authority.

Why should health workers care about violence against women? Violence is a cause of injury and ill health Most women attend health services at some point If health workers know about a history of violence they can give better services for women

Health professionals: Limited knowledge on gender violence Institutional constraints: lack of time, resources Attitudes: fear to offend, blaming No effective interventions Lack of coordination between departments within the health sector (mental health, drugs & alcohol) Lack of coordination between health services and other sectors that deal with gender violence (justice, welfare, NGO networks) Barriers to responding to gender violence in the health sector (1)

”Sometimes when I ask a woman about violence, she dissolves in a sea of tears… then I think “now how am I going to get rid of her?" Doctor in El Salvador

Women are not talking: Shame, embarrassment Lack of confidence in the health worker / system Fear of more violence at home Barriers to responding to gender violence in the health sector (2)

“I said in the hospital that I had fallen, because if I told the truth he would kill me, and I was also ashamed that they would find out that it was my husband who had beaten me.”

Violence is rarely identified in health services In a Nordic study found that 38-66% of women had experienced violence 2-8% had ever confided in their gynecologist

Essential for improved and integrated to response to violence Do no harm Sensitize and train health workers through the integration of violence response into existing health programs Ensure efforts to address violence both within and outside the clinic setting

Impact of screening tool on detection: PLAFAM, Venezuela

What women experiencing violence need from health workers To be listened to A compassionate response Privacy and confidentiality Danger assessment and safety planning Appropriate medical care and documentation Information about rights Referral

Encourage system wide changes Emphasis in many industrialized countries is on training and routine screening Training or screening alone does not lead to sustained changes in health worker behavior or improved outcomes for women unless accompanied by institutional changes Institutional changes include e.g. procedures around patient flow, documentation, confidentiality, feedback to health workers, referral networks

“The doctor helped me feel better by saying that I didn’t deserve this treatment, and he helped me make a plan to leave the house the next time my husband came home drunk.” Woman in the USA

Empowerment based intervention in Hong Kong 30 minute counseling session with abused pregnant Chinese women After 6 weeks intervention group had higher physical functioning and less post natal depression Key factor was opportunity to be listened to and have feelings acknowledged

Address health worker attitudes In South Africa, nurses believed that “women enjoy punishment” (Kim, et al) In Latin America, over 50% of health workers felt that women provoked violence by their behavior (IPPF)

“There are certain behaviours that are expected of a married woman, and if you don't and your husband beats you up, then it's ok. It's like a parent disciplines a child.” Health worker interviewed in Samoa.

For an integrated response we have to look further than the clinic Changing social norms Educate children, young people should be educated in social skills Involve men in violence prevention campaigns Create awareness in families and communities to strengthen support networks

“What helped me the most was the realize that I wasn’t alone. There are many of us who feel trapped and silenced insider ourselves. Learning about laws was also very important to help us break our silence.” Honduran woman from self help group ”

Points to take home Women’s safety and autonomy must be protected Learn from existing projects; training of health workers is an important component Need new indicators for measuring what works Encourage coordination with other sectors

Violence is not acceptable

Sources World Bank Review of Global best practices in gender based violence Ellsberg M. Violence against women and the Millennium Development Goals: Facilitating women's access to support. International Journal of Gynecology and Obstetrics (2006) Thank you!