What if one third of your country’s population suffered from avian flu? Or from hepatitis B? Wouldn’t you expect your government to jump into action over an epidemic of those proportions, to call for an urgent national or global response and universal screening to make sure those who are suffering get the care they need?
But we don’t see that kind of action in the case of violence against women and girls. Worldwide,about 30 percent of all women have at some point experienced physical or sexual violence at the hands of intimate partners. Seven percent of women have been sexually assaulted by someone other than a partner. And globally, as many as 38 percent of all murders of women are committed by intimate partners.
Violence against women exists in epidemic proportions, but it is so normalized and accepted that people don’t recognize it as the large-scale health and human rights disaster that it is.
Health sectors around the world can and should be helping to eliminate violence against women through multilevel, multisectoral interventions. At a minimum, health workers should be trained to screen their clients, identify survivors and connect them to the variety of services and resources they need to heal and move forward with their lives.
But more is required. The health sector must adopt a human rights-based approach to gender-based violence. This means not only promoting and protecting the survivor’s rights in the health facility, but challenging violence and discrimination against women in the community. Health workers can forge partnerships for community education and mobilization or sit on planning councils.
And health care organizations must engage their service providers in new ways of thinking and acting, individually or in coalitions, because the health worker may be the first or only point of contact outside the home for women who are experiencing violence.
Universal screening is a logical first step.
Some researchers worry that universal screening (or routinely asking all clients if they live with violence) might cause more harm than good in settings where few referral services exist, where legal systems are weak and where negative attitudes and lack of training may prevent health providers from responding compassionately to women who disclose abuse.
But even in settings where legal systems are weak and referral services are not available, asking about violence and assuring a confidential response can reassure women that they are not to blame, mitigate isolation, raise women’s awareness about the health risks of violence for themselves and their children, and help women and girls plan for their safety and get help before violence escalates.
Evidence suggests that if health programs implement basic precautions to protect women’s safety as part of a systems approach, the benefits of screening will likely outweigh the risks.
But what is a systems approach? It means transforming the entire health system by strengthening the response to violence throughout each institution, rather than expecting individual providers to shoulder all the responsibility. Some key elements of a systems approach are:
• Well-trained staff with adequate knowledge, attitudes and skills to address gender-based violence.
• Privacy and confidentiality.
• Providing a compassionate response, appropriate medical care and information about legal rights and resources in the community.
• Institutional commitment to human rights.
• Policies that sanction workplace violence and support survivors of gender-based violence among staff.
• Alliances and referral networks with other services for survivors.
• Workable screening policies and care protocols.
I am an advocate of routinely asking women direct questions about violence during health care visits because it may increase the number of women who disclose violence. While the safety of the survivor is paramount, the risks of not screening should be made clear: misdiagnosis or offering inappropriate care; missing an opportunity to counsel, inform and assist before violence escalates; missing an opportunity to empower women to protect themselves; communicating a not-so-benign indifference to women who already feel isolated in their experience of violence; and perhaps worst of all, allowing the health system to be complicit in silencing victims and continuing a longstanding pattern of impunity for perpetrators.
Here are four things health institutions must keep in mind in tackling violence against women:
1. Health workers must understand the strong relationship between exposure to violence and poor health in women, and identify opportunities to link women to other necessary services and resources. A good time to look for those opportunities is when women seek HIV testing, sexual and reproductive health services, mental health care, post-rape services or emergency services.
2. Health workers must know how to care for victims without treating the violence as merely a clinical problem. Providers have the power to assuage victims’ fear of being blamed — or to reinforce those fears, continuing a destructive convention of stigma and silence. When health workers ask about violence in ways that communicate caring and confidentiality, they send the message that the health care system knows that violence is a problem, that violence is not part of a healthy life, and that it is acceptable and normal to talk about it.
3. Health workers should not forget that violence is a human rights violation or undermine efforts to deal with it. For example, health workers should not stress keeping the family together or prescribe tranquilizers (where they are available).
4. Primary prevention — stopping violence before it begins — is as important as treatment and support. Health organizations should seek opportunities beyond the clinic walls to work with community groups and coalitions to raise awareness about violence against women and children, help shelter survivors of violence, challenge the social and gender norms driving the violence, and strengthen community activism to prevent it. Health workers should engage women and girls in meaningful ways in processes of empowerment.
Equipping health workers to effectively screen for and respond to the social roots of gender-based violence helps women who are suffering today, and sets the stage for meaningful health system engagement to prevent violence in generations to come.
As senior team leader for gender equality and health at IntraHealth International, Constance Newman creates practical tools and methodologies to help decision-makers and leaders at all levels understand the challenges of gender inequality and what it means for the health workforce. Newman has over 25 years of experience in health and development, conducting research on gender discrimination in the health workforce in Uganda, Tanzania, Zambia and Kenya.
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