The Crucial Role of Health Services i Respodig to Geder-Based Violece The statistics are staggerig: At least oe out of six wome worldwide ad a majority of wome i some places is physically assaulted or forced to have sex at some poit by their husbads or itimate parters. 1 Usually the violece is ot reported, or is it detected by those i a positio to respod. Such violece is both a health ad huma rights cocer: It iflicts physical ad emotioal harm ad prevets wome from achievig their full potetial. Reports are begiig to emerge o successful resposes to geder-based violece withi health systems. This policy brief examies why health services should address gederbased violece ad highlights examples of health programs that have icorporated resposes to violece ito their work. Program experiece reveals that traiig health care providers ad raisig awareess about geder-based violece will ot be eough. Rather, etire health systems eed to respod, with likages to legal ad social services, to support wome survivors of violece. What Is Geder-Based Violece? Geder-based violece is violece ivolvig me ad wome, i which the female is usually the victim; ad which is derived from uequal power relatioships betwee me ad wome. 2 Due to uequal power dyamics ad lower social status, wome are more likely tha me to be sexually or physically assaulted ofte by their ow husbad, parter, or someoe close to them. Because such violece is rooted i geder iequality, gederbased violece has become a iteratioally accepted term for physical, sexual, ad psychological violece agaist wome. 3 This brief focuses o itimate parter violece (which ca be physical, sexual, or psychological) as well as o sexual violece (rape or coerced sex) by ay perpetrator. Why is Combatig Geder-Based Violece Importat? I 1996, the World Health Assembly declared violece agaist wome to be a major public health problem that urgetly eeded to be addressed by govermets ad health orgaizatios. 4 Studies coducted sice the 1990s cofirm that, while the prevalece of geder-based violece varies across ad withi coutries, it is a sigificat problem early everywhere. 5 For example, atioal surveys i 12 developig coutries foud that betwee 18 percet ad 53 percet of wome had experieced violece by a spouse or itimate parter at some poit i their lives. 6 Geder-based violece causes a host of health problems that strai health systems resources, limit wome s growth ad productivity, impede the well-beig of families ad commuities, ad hider govermets from achievig their atioal goals related to health ad wome s advacemet. The impact of geder-based violece o wome s health, i particular, is well documeted: It is a major cause of disability ad death amog wome worldwide. 7 Geder-based violece has health cosequeces ragig from physical ijury, chroic pai, ad axiety ad depressio to deadly outcomes such as suicide ad homicide. It is a risk factor for may physical, metal, ad sexual ad reproductive health problems. 8 It has adverse cosequeces for wome s sexual ad reproductive health. Physical ad sexual violece ca limit wome s ability to use cotraceptives or persuade their parters to use codoms ad other cotraceptives, puttig wome at icreased risk for uiteded pregacies ad usafe abortio as well as sexually trasmitted ifectios (STIs), icludig HIV/AIDS. 9 Geder-based violece has also bee liked to icreased risk of gyecological disorders ad pregacy complicatios, icludig pelvic iflammatory disease ad miscarriage. 10 Violece durig pregacy ca cause serious harm to both the mother ad fetus. Research shows a close associatio betwee itimate parter violece durig pregacy ad fetal or ifat mortality, developmetal abormalities, low birth weight ifats, ad materal mortality. 11 Health services i developig coutries have bee slow to address geder-based violece. Health care professioals may ot recogize the impact of violece o wome s health or they may cosider it a private, domestic matter that is ot relevat to their work. Moreover, they may be ill-equipped to deal with the problem because medical ad ursig educatio does ot iclude it as a health cocer. Why Are Health Care Professioals Cetral to the Respose? Violece agaist wome is socially acceptable i may societies, ad abused wome may be left with little choice but to suffer i silece. Health care orgaizatios are i a key positio to break the silece ad offer critical care to wome who might otherwise face violece ad its health cosequeces for may years. Health professioals are ofte the earliest poit of cotact for survivors of
violece. As respected members of society, they are also i a uique positio to chage societal attitudes by reframig violece as a health problem. Health professioals who are ot traied to recogize abuse may treat oly the immediate complaits ad miss a opportuity to provide more comprehesive care. Or worse, caregivers may be codescedig toward wome survivors, believig the wome must have doe somethig wrog to warrat the violece. Moreover, health care persoel should be traied to esure that cofidetiality is ot breached, ad that they do ot put wome ad girls at risk of retributio ad additioal violece. 12 What Should Health Services Do to Assist Wome Survivors? The role of health services is to provide immediate medical ad psychological assistace to wome who have bee affected by geder-based violece ad to assist them i avoidig additioal exposure to violece. Both of these compoets are essetial for protectig wome s health. May health care orgaizatios have attempted to address geder-based violece by coductig a sigle traiig evet for selected medical staff or makig a arrow policy chage, such as requirig providers to ask wome about violece. Evidece suggests that these strategies have limited success ad that the best way to respod to the violece is through a systems approach that promotes broad reforms through a health orgaizatio. 13 A systems approach touches o every aspect of health services, from private cosultatio rooms to staff support, supervisio, traiig, ad referral etworks. I fact, chagig the professioal culture of a orgaizatio is ofte ecessary to covice health persoel ad their maagers that respodig to violece agaist wome is a health cocer ad part of their jobs. A systems approach also implies: Improvig health workers ad maagers uderstadig of local ad atioal laws ad policies related to violece; Itegratig attetio to geder-based violece withi health services rather tha settig up parallel services; Supportig log-term efforts to sesitize ad trai health professioals at all levels about geder-based violece; Icorporatig routie screeig for violece i health services provided that wome s cofidetiality ad safety ca be esured; ad Esurig adequate moitorig ad evaluatio of services to survivors of violece. Screeig for physical or emotioal abuse ca be carried out i two ways: i respose to situatios where sigs of abuse are preset or routie screeig for all cliets of a particular service. Routie screeig will idetify more wome facig violece tha if services wait for wome to disclose abuse. Services that focus o emergecy care, psychiatry, gyecological care, sexual ad reproductive health, ad materal ad child health are most likely to see wome who have bee abused ad thus provide a good opportuity to icorporate routie screeig. 14 Oce violece has bee detected, health care providers ca provide wome with the followig (see box o page 3): Medical support, icludig attedig to wome s ijuries ad specialized care for survivors of sexual violece. Accordig to the World Health Orgaizatio, specialized care icludes emergecy cotraceptio where it is approved, provisio of safe abortio services i places where abortio is ot agaist the law, ad post-exposure prevetive treatmet for 15, 16 HIV ad other STIs; Emotioal support, assurig wome that the abuse is ot their fault ad that they ca receive help; Documetatio that ca be used to access the legal system ad support legal proceedigs. The required iformatio is usually spelled out i atioal laws ad regulatios regardig violece agaist wome (where they exist); ad Iformatio about ad referrals to legal aid, couselig services for survivors of violece, support groups, ad places of safety if wome caot retur home. Likages Betwee Health Services ad Other Itervetios Beyod immediate medical attetio, wome survivors of violece may eed psychological support, legal or housig assistace, ad access to employmet. The health sector itself caot respod to all of these eeds. Health services ca lik with social ad legal services that address violece to avoid duplicatio of efforts ad facilitate wome s access to eeded assistace. Health programs ca also play a useful role i broader efforts to prevet violece. By beig egaged i commuity outreach ad advocacy activities, health or- 2 The Crucial Role of Health Services i Respodig to Geder-Based Violece
gaizatios ca stregthe the alliaces or etworks workig o geder-based violece ad raise the visibility of the issue o the atioal ageda. The efforts of a rage of orgaizatios are eeded to brig about chages i cultural orms ad laws ad policies related to geder-based violece. Health Services that Have Respoded to Geder-Based Violece Although few rigorous evaluatios have bee coducted of resposes to geder-based violece withi health services, some useful examples ca be foud i developig coutries. Each of the programs outlied here demostrates a promisig, systematic approach to addressig geder-based violece, ad offers lessos ad guidelies for other orgaizatios that wish to follow a similar path. I Mexico, public hospitals ad health uits developed a Model for Itegrated Attetio to Victims ad Survivors of Sexual Violece i collaboratio with local ad iteratioal orgaizatios, icludig Ipas ad the UN Populatio Fud (UNFPA). The model icludes detectio of violece, medical ad couselig services, iformatio registratio, ad referral to legal ad social services. From 2000 to 2007, more tha 5,400 health professioals (icludig physicias, urses, ad psychologists), social workers, ad justice system persoel were traied o legal issues relatig to violece i Mexico ad o specialized services for wome survivors of violece. 17 I a relatively short period of time, Mexico has made major advaces i istitutioalizig a health systems respose to wome survivors of violece. The itegrated model was iitially tested i Mexico City ad three rural muicipalities ad later expaded to hospitals ad health uits i 12 states ad the Federal District. A atioal certificatio course for sexual violece is ow i place ad, i 2009, followig several years of advocacy by civil society orgaizatios i Mexico, the federal govermet approved a official policy o the treatmet of wome survivors of sexual violece. 18 Ipas ad UNFPA are supportig similar itegrated iitiatives i Bolivia, Brazil, ad Nicaragua. 19 I the Domiica Republic, Profamilia, a affiliate of the Iteratioal Plaed Parethood Federatio, developed a comprehesive service model for addressig geder-based violece withi its etwork of cliics. Profamilia iitially faced reluctace amog health providers to address violece agaist wome ad had limited ifrastructure to atted to survivors eeds. To mout a effective respose, Profamilia realized it would have to create a ew istitutioal culture ad improve its facilities. I the late 1990s, with support from the Bill ad Melida Gates Foudatio, the U.S. Agecy for Iteratioal Developmet, ad other doors, Profamilia bega traiig all cliic staff (icludig receptioists, security guards, physicias, psychologists, ad couselors), developed a stadard process for screeig cliets, ad created private Guidelies for Health Care Providers Oce abuse is idetified, health care providers should focus o four other aspects of care that may eed to be icorporated uder comprehesive services, i accordace with local laws, ad always with wome s coset ad cofidetiality assured. Idetify Abuse Look for sigs ad symptoms of abuse Iquire with sesitivity Assure the cliet of cofidetiality ad make her safety a priority Medical Support Assess for curret ad past icidece of violece Atted to all ijuries Offer specialized services for victims of sexual violece* Emotioal Support Liste carefully Believe i the cliet Covey that violece is ot the cliet s fault Assure the cliet that she is ot aloe Documetatio Register a medico-legal case Make a domestic icidet report Iformatio ad Referral Iform the cliet of her rights Covey the importace of filig a police complait Ask about the cliet s safety Refer the cliet to legal ad social agecies for further help *Accordig to the WHO, specialized services iclude those that protect wome agaist uwated pregacies ad sexually trasmitted ifectios, icludig HIV/ AIDS, as well as psychosocial support. Source: Adapted from CEHAT ad Dilaasa, Guidelies for Health Professioals i Respodig to Wome Facig Violece, www.cehat.org The Crucial Role of Health Services i Respodig to Geder-Based Violece 3
spaces o-site to provide psychological couselig ad legal services. 20 With a evaluatio system i place, Profamilia has leared that the program has chaged the perceptios of service providers ad the cliets they serve. 21 For may wome, the program has bee their first opportuity to discuss violece with ayoe. Some survivors cited their cotact with a health provider as their first step o the road to seekig help. The attitudes of may cliicias also chaged; the tedecy to blame the victim dropped dramatically ad all providers agreed that female cliets should be asked systematically about violece. The program still faces challeges such as garerig sufficiet fuds to support the itegrated service model ad providig ogoig social support to providers who work with survivors. O a broader level, Profamilia has received high marks for its iformatio ad advocacy activities that have egaged commuities, the judicial sector, ad the atioal govermet i combatig geder-based violece. 22 I Keya, the ogovermetal orgaizatio, Liverpool VCT & Care Keya (LVCT) coducted operatios research i three districts i 2003 to develop ad implemet a stadard of care for postrape services. LVCT provides HIV prevetio ad treatmet services, icludig volutary testig ad couselig, ad carries out research ad advocacy to iform HIV/AIDS policies ad services i Keya. Because wome survivors of sexual violece are at high risk of HIV ifectio, LVCT wated to help health program maagers ad providers better uderstad sexual violece ad test the feasibility of providig care to survivors. Usig a participatory approach amog staff ad maagers ivolved i the program, LVCT developed a stadard of care that icluded emergecy medical services, laboratory testig, couselig, preparatio for the justice system, ad post-exposure drug treatmet for HIV ad other STIs. 23 As of early 2010, LVCT reports that its post-rape care program has traied 570 cliicias, urses, laboratory persoel, ad trauma couselors who have provided services to 9,500 survivors i 19 itegrated post-rape care sites i Keya. LVCT s research iformed the developmet of atioal guidelies o the medical maagemet of rape ad traiig curricula by the Miistry of Health s Divisio of Reproductive Health. 24 I Idia, the ogovermetal orgaizatio, CEHAT (Cetre for Equiry ito Health ad Allied Themes), worked with the public health departmet i Mumbai to develop Idia s first hospital-based crisis ceter for wome facig domestic violece. CEHAT is a research, traiig, ad advocacy orgaizatio that develops programs to demostrate how health services ca better meet the eeds of margialized people. The crisis ceter, Dilaasa (meaig reassurace ), provides social ad psychological support to wome survivors as well as referrals to shelters, legal aid agecies, ad other wome s orgaizatios. 25 It also facilitates survivors access to medical care such as emergecy cotraceptio ad metal health services. Iitially established i oe hospital i Mumbai to make the public health system accoutable o the issue of violece agaist wome, it ow operates i three hospitals, has traied staff from 16 hospitals (icludig doctors, urses, ad social workers), ad has helped thousads of wome facig domestic violece to access services easily. 26 Still, challeges remai, such as expadig the work to other levels of the public health system, icludig primary health care, icorporatig geder-based violece ito the medical curriculum, ad sustaiig the traiig ad services after CEHAT withdraws. 27 To help other health care orgaizatios establish services for wome facig domestic violece, CEHAT has produced iformatio for cliets ad providers, service tools, ad guidelies. CEHAT has also developed the Sexual Assault Foresic Evidece Kit (SAFE Kit) ad a protocol for usig it, implemeted i two Mumbai hospitals i 2008. Beyod use of the evidece kit, CEHAT is advocatig for a comprehesive respose to sexual assault withi the health system that icludes psychological support ad likages to other agecies to meet survivors eeds for rehabilitatio ad legal assistace. 28 Gaps i Kowledge ad Practice Despite these promisig approaches, i most coutries the health care system remais a key but uderutilized etry poit through which to idetify ad assist victims of gederbased violece. Iformatio o the costs of implemetig such services is scarce; however, the costs of geder-based The Crucial Role of Health Services i Respodig to Geder-Based Violece 4
violece to the health system ad the ecoomy are icreasigly well-documeted. 29 Cost-effectiveess aalysis ca demostrate that addressig geder-based violece i health care settigs will provide et savigs i terms of improved outcomes ad reduced expeditures o health, social, ad legal services. 30 A recet study i the UK foud that a traiig program for primary-care teams to icrease idetificatio ad referral of wome experiecig itimate parter violece is likely to be cost-effective. 31 Next Steps Policymakers, health program maagers, educators, ad fuders all must play a role i esurig that the health system respods to geder-based violece. Such a respose is critical for combatig a hidde but pervasive problem ad protectig wome s health ad rights. Policymakers should: Commit publicly to address geder-based violece as a huma rights ad public health cocer ad esure availability of fudig; Approve guidelies ad protocols for stadard treatmet of wome survivors of violece; Fud traiig o geder-based violece for health professioals ad isist o chages to health educatio curricula to iclude geder-based violece; ad Support likages betwee law eforcemet, health services, ad other services to support survivors of violece. Additioal Resources Bott, S., A.Guedes, M.C. Claramut, ad A. Guezmes. Improvig the Health Sector Respose to Geder-Based Violece: A Resource Maual for Health Care Professioals i Developig Coutries. New York: Iteratioal Plaed Parethood Federatio, Wester Hemisphere Regio, 2004. www.ippfwhr. org/e/ode/288 Trocoso, E., D.L. Billigs, O. Ortiz, ad C Suárez. Gettig It Right: A Practical Guide to Evaluatig ad Improvig Health Services for Wome Victims ad Survivors of Sexual Violece. Chapel Hill, NC: Ipas, 2006. www.ipas.org UNFPA. A Practical Approach to Geder-Based Violece: A Programme Guide for Health Care Providers & Maagers. New York: UNFPA, 2001. www.ufpa.org Health program maagers must: Uderstad ad educate staff o the likages betwee geder-based violece ad health, particularly reproductive health; Itegrate a comprehesive set of resposes to violece withi health services, icludig cofidetial screeig, emotioal ad medical support, ad referrals to other services that support survivors; Esure that wome s privacy ad safety ca be protected before iitiatig routie screeig; ad Form likages across sectors (e.g., cliics, shelters, police, ad legal etworks) to be able to provide comprehesive services to wome survivors. Istitutios that trai health professioals eed to: Revise traiig curricula for doctors, urses, ad other health persoel to iclude uderstadig ad respodig to geder-based violece. Fudig agecies should: Ivest i research to build the evidece base about how best to itegrate geder-based violece i health services. This icludes: > Supportig pilot itervetios to demostrate how service itegratio ad likages work i differet settigs; > Supportig studies that examie the costs of itegratig geder-based violece ito health services; ad > Fudig evaluatios of programs that itegrate geder-based violece ad health services. This brief was writte by Lori Ashford, cosultat, ad Charlotte Feldma-Jacobs of PRB, with the assistace of may idividuals, especially Alessadra Guedes of PAHO, Sageeta Rege of CEHAT, ad Jay Gribble of PRB. It was produced by PRB for the Iteragecy Geder Workig Group (www.igwg.org), with fudig provided by USAID uder the BRIDGE Project (Cooperative Agreemet GPOA-00-03-00004-00). The views ad opiios of the authors expressed herei do ot ecessarily state or reflect those of the Uited States Govermet or the U.S. Agecy for Iteratioal Developmet. 5 The Crucial Role of Health Services i Respodig to Geder-Based Violece
Edotes 1 S. Kishor ad K. Johso, Profilig Domestic Violece A Multi-coutry Study, Calverto, MD: ORC Macro, 2004. 2 Uited Natios Populatio Fud (UNFPA), Geder Theme Group, 1998. 3 Iteragecy Geder Workig Group (IGWG), Addressig Geder-based Violece through USAID s Health Programs: A Guide for Health Sector Program Officers. Washigto, DC: IGWG, 2006. 4 Resolutio WHA49.25 of the Forty-ith World Health Assembly, Geeva: WHO, 1996. 5 E. Krug et al., eds., World Report o Violece ad Health, Geeva: World Health Orgaizatio, 2002; ad C. Garcia-Moreo et al., WHO Multi- Coutry Study o Wome s Health ad Domestic Violece agaist Wome: Iitial results o prevalece, health outcomes ad wome s resposes, Geeva: WHO, 2005. 6 S. Kishor ad K. Johso, Profilig Domestic Violece, 2004. 7 E. Krug et al., eds., World Report o Violece ad Health, 2002. 8 S. Bott et al., Improvig the Health Sector Respose to Geder -Based Violece: A Resource Maual for Health Care Professioals i Developig Coutries, New York: Iteratioal Plaed Parethood Federatio, Wester Hemisphere Regio, 2004: 4. 9 C. Garcia-Moreo et al., WHO Multi-Coutry Study o Wome s Health ad Domestic Violece agaist Wome: Iitial Results o Prevalece, Health Outcomes ad Wome s Resposes, 2005; R. Jewkes et al., Itimate Parter Violece, Relatioship Power Iequity, ad Icidece of HIV Ifectio i Youg Wome i South Africa: A Cohort Study, The Lacet, Early Olie Publicatio, 16 Jue 2010. 10 J. Campbell et al., Health Cosequeces of Itimate Parter Violece, The Lacet 359(2002):1331-1336. 11 S. Jejeebhoy, Associatios Betwee Wife-Beatig ad Fetal ad Ifat Death: Impressios from a Survey i Rural Idia, Studies i Family Plaig 29, o. 3 (1998):300-8. 12 M. Colombii, S. Mayhew, ad C. Watts, Health-Sector Resposes to Itimate Parter Violece i Low- ad Middle-Icome Settigs: A Review of Curret Models, Challeges, ad Opportuities, Bulleti of the World Health Orgaizatio 86, 2008:635 642. 13 L. Heise et al., Edig Violece Agaist Wome, Populatio Reports Series L, o. 11, Baltimore, MD: JHUCCP, 1999. 14 CEHAT, Guidelies for Health Professioals i Respodig to Wome Facig Violece, Mumbai: CEHAT, [ND]. 15 WHO, Guidelies for Medico-Legal Care for Victims of Sexual Violece 2003, accessed o Jue 1, 2010 at http://whqlibdoc.who.it/ publicatios/2004/924154628x.pdf 16 U.S. law prohibits the use of U.S. foreig assistace fuds to pay for the performace of abortio as a method of family plaig to motivate or coerce ay perso to practice abortio, ad to lobby for or agaist abortio. 17 UNFPA, Programmig to Address Violece Agaist Wome: 10 Case Studies, New York: UNFPA, 2007: 65-73. 18 Chistopher Bross, Ipas, persoal commuicatio, March 17, 2010. 19 UNFPA, Programmig to Address Violece Agaist Wome: 10 Case Studies, 2007. 20 S. Bott et al., Improvig the Health Sector Respose to Geder -Based Violece; ad R. Goldberg, Livig Up to Their Name: Profamilia Takes o Geder-based Violece, Quality/Calidad/Qualité o. 18, New York: Populatio Coucil, 2006: 5-31. 21 R. Goldberg, Livig Up to Their Name, pp. 20-23. 22 USAID, Fial Evaluatio Study of the Project Geder-Based Violece, Reproductive Health, ad Rights i the Domiica Republic, Upublished, 2009. 23 N. Kilozo, Liverpool VCT s Post-Rape Care Services i Keya, Presetatio at the IGWG Task Force o Geder-Based Violece Techical Update, Washigto, D.C., Nov. 8, 2007. 24 Liverpool VCT, Servig Vulerable ad Most at-risk Populatios, accessed Jue 1, 2010 at www.liverpoolvct.org/idex.php?pid=149; Liverpool VCT, Comprehesive Post-Rape Care Services i Resource-poor Settigs: Lessos Leart from Keya, Policy Briefigs for Health Sector Reform o. 6, Sept. 2005. Accessed Jue 1, 2010 at www.liverpoolvct.org/images/ dowloadable/prc%20policy%20briefig.pdf. 25 S. Rege, Challeges i Sustaiig a Hospital-Based Crisis Cetre: Learigs of the First Hospital-Based Crisis Cetre i Idia, Presetatio at the Secod IGWG Techical Update o Geder-Based Violece, Washigto, DC, Nov. 2005. Accessed Jue 1, 2010 at http://www.igwg.org/evets/ IGWGSecodGederBasedTechUpd.aspx. 26 CEHAT, Curret Projects [Website], Accessed Jue 1, 2010 at www. cehat.org/go/curretprojects. 27 S. Rege, Challeges i Sustaiig a Hospital-Based Crisis Cetre, Nov. 2005. 28 CEHAT, A Comprehesive Health Sector Respose to Sexual Assault: Does the Delhi High Court Judgmet Pave the Way? CEHAT Workig Paper Series 2, Mumbai: CEHAT, 2010. 29 T. Dolezal, D. McCollum, ad M. Callaha, The Hidde Costs i Health Care: The Ecoomic Impact of Violece ad Abuse, Ede Prairie, MN: Academy o Violece ad Abuse, 2009. 30 R. Norma, A. Specer, ad G. Feder, Cost-Effectiveess Aalysis: What You Always Wated to Kow but Were Afraid to Ask. Accessed Jue 1, 2010 at www.edabuse.org/health/ejoural/archive/1-5/ 31 R. Norma, A. Specer, S. Eldridge, ad G. Feder, Cost-effectiveess of a Programme to Detect ad Provide Better Care for Female Victims of IPV, i Joural of Health Services Research & Policy 15 (2010): 143-149. PRINTED WITH SOY INK TM