Sex-trade workers experience a high
incidence of violence in the context
of disregard for their right to respect
and safety.
REDUCING HARM
AND IMPLEMENTING
BEST PRACTICES
The health-care system response to abuse should reflect
the complexity of a woman’s experience of abuse, the
impact of violence on her health, her ability to access
and utilize health care, and compounding factors in her
life that further increase her risks. Any model of health
care for women experiencing abuse must encapsulate the potential
for both compounding health burdens and increasing risks
by the system.
Jill Cory (Coordinator of the Woman Abuse Response Program
at BC Women’s Hospital) and Lynda Dechief (Research
Consultant, Women’s Abuse Response Program, and Coordinator
of the Maxxine Wright Place Project for
High Risk Pregnant and Early Parenting
Women, Atira Women’s Resource
Society) have developed an analysis of
the challenges facing the health-care
system in developing and implementing
best practices for women who experience
intimate-partner violence (Aid to Safety
Assessment and Planning [ASAP] for
Health Care Providers, BCIFV, in
process). They conclude that, “We need
to develop a health care structure and
a practice that starts from the premise
that every woman could be experiencing
abuse, but that not every woman
is experiencing abuse. We cannot
assume that a woman will volunteer
information about the risks she faces
in her relationship, so it is incumbent
upon the system to reduce the potential
risks inherent in health systems and
increase the protective measures to
ensure women’s safety to the greatest
possible degree.” This must be done
without relying on a disclosure of abuse;
women may not and should not have
to ‘disclose’ in order to receive adequate
and respectful care and, therefore, the
primary changes must be systemic rather
than individual in nature.
VIOLENCE AND HEALTH CARE
MODEL
The ASAP Manual for Health Care Providers describes two
inter-related conceptual models. The first model identifies
the risks to women within the context of health and health
care, beginning with the abuse itself and compounded by
different layers of the health-care system and society’s
response. The second model is an inverted depiction of the
first and leads to protective measures that reduce the risks
to women and mitigate the harms of the abuse by her partner.
Both models are six-tiered.
The first model includes:
• First Tier. The abuse a woman
experiences in her intimate relationship
• Second Tier. The impact of the
abuse on her health
• Third Tier. The impact of the
abuser or other barriers on her access to health care
• Fourth Tier. The impact of routine
practices and the institutional culture in which health
services are delivered, both of which rely on a hierarchical
model of care in which the abuse a woman has experienced
is echoed in the care she receives (ie, loss of autonomy,
disempowerment, lack of attention to safety)
• Fifth Tier. The social circumstances
and structural inequities that have an impact on health,
such as living
in poverty, being an Aboriginal,
immigrant, or refugee woman, or
using substances
• Sixth Tier. The contexts of gender
and social inequality that reify discriminatory attitudes
and social norms through policies and other social institutions
Each tier adds to the health burden on women in abusive
relationships and compounds the impact of the initial harms
caused by the abuse.
INVERTING THE MODEL: PROTECTIVE MEASURES
The risk model described above illustrates how a woman’s
safety and long-term health are jeopardized by inadequate
or inappropriate responses from professionals, institutions,
and public policy. Inverting the model can help health-care
providers understand how services that unwittingly harm
women can be reorganized to offer protective measures.
The goal of protective measures is to create a safe environment
during a woman’s contact with the health-care service,
empower her to improve her safety and well-being, strengthen
her ability to respond, and provide relevant health care.
The objective is to support the woman in her efforts to
address her health concerns by reducing her barriers to
access, avoiding re-traumatization, reducing the impact
of gender and cultural biases, creating gender-fair policies,
reviewing practices through a women-centred lens, and creating
safety at all levels of health care. The role of health-care
providers therefore includes reviewing or auditing all health
services and systems for areas of practice and policy that
increase potential harms to women, and replacing potentially
harmful policies and practices with protective measures
that reduce the overall burden on women.
When the pyramid is inverted to a ‘protective-measures’
framework, the abuse (First Tier) is not supported or compounded
by the other tiers. Institutions, and their policies and
practices, recognize the risks faced by abused women, and
value and support their health and safety. In a protectivemeasures
framework, the impacts of abuse on a woman’s health
are mitigated by a health-care system that makes the connections
between violence
and health, and supports women in a
manner that counters the dynamics of
abuse—ie, with mutuality and respect.
The woman’s health (Second Tier) is
strengthened and she is more able to
safeguard herself within her abusive
relationship.
In a protective-measures framework, the barriers to access
(Third Tier) created by negative health-care experiences
and organizational structures are addressed. Health-care
providers are aware that a woman’s increased physical,
emotional, and ?nancial dependence on her partner can reduce
her freedoms and basic human rights. Women do not need to
fear that the dynamics of their abusive relationships will
be echoed in healthcare encounters. Efforts are made
toward creating a health-care system
that is equally accessible to all women
experiencing abuse, and that accounts
for the social determinants of health.
Traditional medical approaches (Fourth Tier) can re-traumatize
women, shift the focus away from women’s health concerns,
and re-create the ‘power-and-control’ dynamics
of abuse. In a protective-measures model, the focus shifts
from changing women to changing the problem. The system
is organized on the basis that women are at the centre of
care and that decisions made about their health, health
treatments, advice, service options, and care all take place
recognizing the possibility of their having experienced
abuse at some point in their lives. Ideally, all health
care is provided in the context of a woman’s life,
with her safety and life circumstances at the forefront.
At the very least, interactions with health-care providers
do no harm. At best, the health-care experience supports
women in their efforts to regain control of their lives
and health.
Social determinants of health (Fifth Tier) compound the
risks and health impacts of abuse, and affect women’s
access to and experiences in the health-care system. Factors
such as being young, old, poor, Aboriginal, immigrant, refugee,
disabled, lesbian, bisexual, and/or transgendered can make
it even more difficult for a woman to gain access to resources,
leave an abusive relationship, and find appropriate and
safe services, including health care. Life circumstances,
such as substance use or mental illness, are viewed as potential
impacts of abuse, and women and their health concerns are
treated accordingly. In a protective-measures conceptual
model, social determinants of health are recognized and
incorporated into all aspects of health care, making health
care truly accessible to all women. This approach places
the onus on systems and institutions to develop new responses,
rather than on expecting women to change or conform. The
expectation that women disclose abuse simply because health-care
providers ask them to oversimplifies the complex interaction
of women’s experiences and the multiple pressures
they endure.
By ignoring that violence is rooted in gender inequality
and oppression (Sixth Tier), ‘gender-blind’
policies and practices recreate the social context in which
violence against women is perpetuated. A protective-measures
approach assists health-care providers, planners, decision-
and policy-makers to conceptualize a multi-tiered healthcare
response organized around such fundamental principles as:
do no harm; understand and avoid re-traumatization; address
women’s health concerns; and adapt treatment protocols
to increase women’s safety within the context of health
services.
BEST PRACTICES
Victims of violence have a right to health care that acknowledges
the root causes of their health issues. Women are experts
on their own lives and have a right to make health-care
decisions autonomously. Based on the literature and local
practice, the 2000 Working Group on the Continuum of Violence
Services, chaired by BCIFV, provided examples of best health-care
practices for responding to women who have experienced intimate-partner
violence.
These include:
• Promoting access to community services, and therefore
knowing the resources in the community such as crisis lines,
transition houses, and/or sexual-assault services.
• Respecting confidentiality, which is essential to
building trust and ensuring women’s safety.
• Respecting women’s autonomy by respecting
their right to make decisions in their lives, when they
are ready, based on the understanding that they are the
experts in their lives.
• Helping women plan for safety within the context
of health-care settings, as well as their future safety
within their relationships. Making their safety paramount.
Finding out what they have tried in the past to reduce the
risks to their safety.
• Recognizing that working with traumatized women
requires complex skills reinforced by up-to-date training.
• Advocating for adequate individual, group, or self-help
counselling services.
• Ensuring that health settings address issues of
racism, homophobia, ageism, and other mainstream belief
systems that compound the harms to women.
HEALTH-SYSTEM POLICIES AND PROTOCOLS
The 2000 Working Group on the Continuum of Violence Services
recommended that health authorities should:
• Develop and adopt a regional healthpolicy statement
on intimate-partner violence that includes a statement regarding
diversity and inclusiveness, based on an understanding of
gender, of the power dynamics of violence, of the barriers
women face, and of the impact of violence on women’s
health.
• Develop goals of practice (in terms of locally researched
outcomes for women) and best practices based on protocols
and guidelines, and assign authority and responsibility
for the implementation of violence-against women best practices
to health-care providers in the region.
• Establish baseline statistics in the region for
such outcomes as the number of women turned away from emergency
housing per year, the number of police calls resulting in
charges being laid, and the utilization rates for services
such as woman assault and sexual-assault centres. Include
fields related to the abuse of older women.
• Using these baselines, set realistic goals for reducing
violence in the region and assign responsibility for dealing
with violence against women at all service levels, including
a requirement that all managers support staff to implement
goals and evaluate outcomes.
• Provide support for ongoing training, including
staff release time, to sustain protocols and ensure that
all healthcare providers achieve agreed-upon knowledge and
skills to intervene effectively in cases of violence against
women, particularly in cases where women are further marginalized.
Two priorities are training for anti-violence and mental-health
workers on abuse of seniors, and learning more about each
other’s services in order to work more effectively
together.
• Support development of a core curriculum for undergraduate
and post-graduate education for all professionals who might
come in contact with abused women.
• Ensure that workplaces have policies and procedures
in place that: create a safe and supportive work environment,
including responsiveness to employees who are abused; and
encourage the hiring of women from diverse cultures in order
to provide culturally appropriate services; and ensure employee
assistance programs are responsive to women who experience
violence.
SHOULD HEALTH-CARE PROVIDERS SCREEN FOR WOMAN ABUSE?
A major issue regarding the health-care system’s
response to intimate-partner violence is whether health-care
providers should routinely screen all patients for abuse.
While the health sector’s effort to develop its role
is still in its infancy, early development work in the area
of violence against women relied on a common medicalized
approach to address the problem. ‘Screening’
is an approach used to identify (diagnose) and treat health
problems and has led some health researchers and planners
to recommend a universal screening approach to domestic
violence as a way of identifying the problem of abuse.
While the focus on implementing screening has raised some
awareness regarding the need to develop a response to woman
abuse in health settings, there is no evidence that screening
has transformed the social beliefs, routine practices, and
social and health policies that place women’s safety
at risk within health-care settings. While health professionals
have been described by some as ideally placed to identify
intimate-partner violence, a failure to acknowledge women’s
safety, social, cultural, legal, and economic realities
makes many women reluctant to volunteer this information
to professionals located in institutional settings that
historically have been disempowering to women.
The reality is that aspects of the abuser’s violence
may remain hidden because of gender stereotypes of appropriate
male behaviour (Campbell, 1995) or because women with violent
partners may assume responsibility for the abuse, assume
blame for causing it, or reject stigmatizing labels. As
a result, women may name experiences as abusive only in
retrospect (Kelly, 1988; MacLeod, 1987) and may therefore
not identify with standardized screening questions. When
surveyed, “women ‘discounted’, ‘underestimated’, ‘downplayed’
or ‘normalized’ the violent behaviour of their male partners
by describing it as ‘excusable’ or ‘understandable’. Women
with violent partners also often assumed responsibility
for a violent incident, blamed themselves for causing it
and worried that their partner’s reaction to the incident
could contribute to further violence.” (Bagshaw and Chung,
2000: 7-8) Therefore, service providers should never assume
that they know the full extent of violence that is occurring
(Campbell, 1995) simply because they have inquired about
it.
A 2003 report by the Canadian Task Force on Preventative
Health Care, an independent panel funded by Health Canada,
concluded that due to a lack of appropriate clinical studies,
there is insufficient evidence to recommend for or against
routine universal screening for violence against either
pregnant or non-pregnant women. Health-care providers’ decisions
to inquire about violence should be guided by factors unique
to each clinical encounter. These include: what services
might be available in the community; the woman’s specific
situation, including the severity of abuse; her immediate
concerns regarding her own safety and that of her children;
and her own assessment of the benefits and risks of disclosing
abuse (for example, whether she currently feels able to
seek help or fears reprisal violence from her abuser). (MacMillan
and Wathem, 2003)
A British systematic review of screening for domestic violence
in health-care settings concluded that there was insufficient
evidence to recommend screening programs, and highlighted
the importance of educating and training clinicians to promote
appropriate health-care responses. (Ramsey, et al, 2002:
314) A similar study by the third US Preventative Service
Task Force found that, due to a lack of studies, there is
no direct scientific evidence to determine the balance between
benefits and harms of screening for intimatepartner violence.
TRAINING
All health-care providers must have appropriate training
to provide adequate health-care responses to women who experience
violence, including linking health-care concerns with the
impact of abuse.
Examples of publications describing training programs include:
• The 1999 Canadian publication A Handbook Dealing with
Woman Abuse and the Canadian Criminal Justice System: Guidelines
for Physicians, by LE Ferris, A Nurani, and L Silver, published
by the National Clearinghouse on Family Violence and available
at http://www.phacaspc. gc.ca/ncfv-cnivf/familyviolence/
pdfs/physician_e.pdf.
• The 1998 US publication Improving the Health Care Response
to Domestic 2003) Violence: A Resource Manual for Health
Care Providers by Carole Warshaw and Anne Ganley, published
by the Family Violence Prevention Fund and available at
http://endabuse. org/programs/healthcare/.les/ trainersmanual/Preface.pdf.
• “Advancing Healthcare Practice” (see box on page 19).
BC Women’s Hospital and Health Centre is a provincial leader
in women’s health care and research. The Woman Abuse Response
Program at BC Women’s has been developing an innovative,
women-centred approach to woman abuse in the context of
women’s health and health services throughout BC. In addition
to providing training in partnership with communities and
health authorities across BC, the program has developed
a women-centred model consistent with the standards of care
developed by the community-based women’s advocacy sector.
This ensures that women’s safety is paramount and that health
services, guidelines, and research reflect women’s experiences
of abuse, and avoid duplicating the power and control that
abused women experience in their relationships. The training
also provides practitioners with information and tools,
including model protocols, documentation guidelines, and
safety and security planning with women, while they are
in health-care settings.
PUBLIC HEALTH, HEALTH PROMOTION, AND FAMILY VIOLENCE
Research shows that lifetime exposure to violence against
women in relationships has signi.cant short- and long- term
health consequences. A concerted health promotion response
is needed to identify methods to reduce the Services that
unwittingly harm abused women can be reorganized to offer
protective measures. impact of intimate-partner violence
on health and to prevent intimate-partner violence. For
an excellent overview of the connection between family violence
and public health, see the US Family Violence Prevention
Fund tool Domestic Violence and Public Health by Lynda Chamberlain
(CD and guidebook; power point slides at http://endabuse.org/programs/display.
php3?DocID=344). This evidence-based tool describes the
relevant research on family violence, implications for selected
public-health programs, recommended clinical and policy
strategies, promising practices, and resources.
Examples of Canadian health-promotion projects include:
• The National Clearinghouse on Family Violence, operated
by Health Canada.
• The Canadian Health Network Violence Prevention website,
comanaged by BCIFV until March 2004.
Examples of American health-promotion projects include:
• The National Health Initiative’s Ten- State Program.
Developed to model health-care projects to respond to domestic
violence, this program resulted in hundreds of sustainable
programs.
• The National Health Care Standards Campaign to develop
new multidisciplinary clinical guidelines on domestic violence
and a large-scale, public-health campaign.
• The California Clinic Collaborative on Domestic Violence
to assist 20 community-health clinics in improving their
response to family violence and developing public education
and outreach.
• The Indian Health Service Domestic Violence Demonstration
Project to strengthen domestic-violence prevention strategies
in 15 American Indian/Alaska Native health-care facilities.
CONCLUSION
Woman abuse is a health-care issue. Women-centred care
ensures that women have a right to health care that acknowledges
the root causes of their health issues. An individual woman’s
circumstances are so complex as to require a tailored health-care
response to each case, based on an understanding of the
relevant risk and safety factors, as well as a systemic
approach that transforms health services with the goal of
reducing the risks and barriers women may face and increasing
the protective measures within the health- care framework.
Health-care providers also need to work in collaboration
with other justice and social-service system workers to
empower women to address their safety and health needs.
Jill Cory currently coordinates the Woman Abuse Response
Program at BC Women’s. For the past 22 years, she has worked
as an advocate in transition houses, support groups, and
the health system to improve support for women. Penny Bain,
LLM, has been the Executive Director of the BC Institute
Against Family Violence for the past seven years. She leaves
this position on May 31, 2005 to take up a new posting as
Executive Director of the BC Coalition to Eliminate Abuse
of Seniors.
REFERENCES
Bagshaw, D, and Chung, D (2000) “Gender politics and research:
Male and female violence in intimate relationship,” in Women
Against Violence: An Australian Feminist Journal, 8: 4-23.
Campbell, JC (1995) “Violence research: an overview,” in
Scholarly Inquiry for Nursing Practice, 9(2): 105-26.
Kelly, L (1988) “How women de.ne their experiences of violence,”
in Feminist Perspectives on Wife Abuse, Yllo, K, and Bograd,
M, (Ed’s) Thousand Oaks CA: Sage Publications.
MacLeod, L (1987) Battered but Not Beaten: Preventing Wife
Battering in Canada, Ottawa: Canadian Advisory Council on
the Status of Women.
MacMillan, H, and Wathem, N (2003) “Commentary: Violence
against women: Integrating the evidence into clinical practice,”
in Canadian Medical Association Journal, Sept. 16, 2003;
169 (6).
Ramsey J, Richardson J, Carter YH, Davidson L, and Feder
G (2002) “Should health professionals screen women for domestic
violence? Systematic review,” in BMJ; 325: 14.
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