SOGCs Violence Against Women Program

1
SOGCs Violence Against Women Program

• Encouraging Physicians Involvement in the
  Identification and Eradication of Violence
  Against Women

Society of Obstetricians and Gynaecologists of
Canada
2
Acknowledgements

• This series of slides was put together with
  material/resources from the following
• 1 - Tinker, Ann, Womens Health and
  Development. FIGO World Congress, Washington,
  DC, September 2000.
• 2 - Physicians Health Network, Violence Against
  Women Empower Education Program A practical
  guide for health professionals, 1996.
• 3 - Family Care International, Advancing Sexual
  and Reproductive Health Commitments, Violence
  Against Women CD Rom Resource Tool, developed
  2000.
• 4 - Warshaw, Carol Domestic Violence and
  Womens Health Barriers to Health Sector Change
  Chicago, IL.
• 5 - Ellsberg, Mary and Heise, Lori, Ending
  violence against women a multicultural
  perspective Naples, Italy, October 16, 2000.
• 6 - Society of Obstetricians and Gynaecologists
  of Canada.

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WHO Prerequisites for Health
State of complete physical, mental and social
well-being, not merely the absence of disease or
infirmity.

• Freedom of fear of war or violence
• Equal opportunity for all
• Satisfaction of basic need for food, water,
  sanitation, housing, secure work and a useful
  role in society
• Political will and public support

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Global Overview of Womens Health

• Women have more illness and disability than men
• Womens poor health reflects their status in
  society, as well as their reproductive role
• Improving womens health is critical to achieving
  wider social and economic development goals

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In Addition to Reproductive Risks

• Women have higher death and disability from
  depression, domestic violence, and sexual abuse
• Compared to the main causes of mens burden of
  disease, which includes injuries and substance
  abuse

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Violence Against Women

• Men rape within the marriage.
• Men believe that paying dowry means buying the
  wife,
• so they use her anyhow at all times.
• But no one talks about it.- -
• Uganda, Voices of the Poor

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Violence Against Women

• Any gender-based act or conduct that results in,
  or is likely to result in, physical, sexual, or
  psychological harm or suffering to women
• One-quarter to one-half of all women have been
  physically abused by a current or former partner.
  Over 50 of women who are physically abused by
  their partners are also raped by them

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Violence Throughout a Womans Life Cycle

• Childhood
• Child marriage
• Incest
• Female Genital Mutilation

• Childhood, adolescence and adult life
• Denial of education, health care or food
• Early or unwanted pregnancy
• Sexual harassment
• Trafficking
• Rape
• Honor killings
• Forced labour

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Violence Against Women

• Physical violence usually occurs together with
  emotional violence
• 3-20 of women experience violence during
  pregnancy
• Between 16-50 of women worldwide have
  experienced physical partner abuse

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Physical violence usually occurs together with
sexual and emotional violence

• Among 613 ever-abused Japanese women, 57
  experienced all three types of abuse
• Globally, one-third to one-half of all physically
  abused women also report sexual violence
• Almost all physically abused women also
  experience severe emotional abuse (i.e. 97 of
  women physically abused in Leon, Nicaragua were
  also emotionally abused)

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Gender and Violence

• Violence against women is deeply rooted in male
  and
• female gender roles in society and in individual
  relations.
• Many family laws and customs implicitly consider
  women to be property of male-headed households
• Men are pressured by society to establish their
  authority and power in the home often through
  verbal, emotional, or physical violence against a
  partner or children
• Women and men are often taught to believe that
  violence can be acceptable to keep women in line

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Beating as Discipline

• I think that if the wife is guilty, the husband
  has the right to hit herIf I have done something
  wrongnobody should defend me. But if I havent
  done something wrong I have a right to be
  defended.
• Indigenous woman, Mexico

• If it is a great mistake, then the husband is
  justified in beating his wife. Why not? A cow
  will not be obedient without beatings.
• Rural Man, Tamil Nadu, India

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Abusers Control of Health Care

• Controls medication
• Controls appointments
• Controls finances
• Controls information
• Controls sleep, food and basic functions
• Controls legal process

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Health Consequences of Abuse

• Fatal Outcomes
• Homicide
• Suicide
• Maternal deaths
• AIDS-related deaths
• Non-fatal outcomes
• Unwanted pregnancy
• Chronic pain syndrome

• Injury
• Depression
• Alcohol/drug use
• STDs/HIV
• Irritable bowel syndrome
• Gynecological disorders
• Low birth weight

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Violence Against Women Mental Health
Consequences

• Depression
• Panic Disorder
• Eating Disorder
• Dissociative Disorder
• Substance Abuse
• Psychotic Episodes
• Acute and Post Traumatic Stress
• BPD/Complex PTSD/DESNOS

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Violence Contributes to Adolescent Pregnancy

• Childhood sexual abuse

Greater likelihood of teen pregnancy
Younger age at first intercourse
Increased risk behaviors such as sex with many
partners
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Violence Leads to Unwanted Pregnancies

• Domestic violence is more common in families with
  more than 4 children
• Some studies suggest that onset of abuse
  generally precedes childbirth and that it may be
  a risk factor for large families rather than the
  reverse

• Bolivia
• Chile
• India
• Nicaragua
• Philippines
• United States

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Violence Reduces Womens Sexual Autonomy

• In many parts of the world, marriage is
  interpreted as granting men unconditional sexual
  access to their wives, a right enforced through
  force if necessary

• Among 98 currently married women in U.P. India,
  68 reported being coerced into sex by their
  husbands 31 report being forced through
  beatings
• Khan, 1996

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• What can I do to protect myself from these
• unwanted pregnancies unless he agrees to do
• something? Once when I gathered the courage
• and told him I wanted to avoid sex with him, he
• said what else have I married you for? He
• beats me for the smallest reasons and has sex
• whenever he wants.
• 40 year old woman, UP, India

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Violence Increases Risk for Other Gynecological
Problems

• A history of sexual violence has been
• associated with
• Vaginal bleeding
• Vaginal discharge
• Painful menstruation
• Sexual dysfunction
• Pelvic inflammatory disease
• Painful intercourse

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Violence may also be linked to chronic pelvic
pain (CPP)

• Chronic pelvic pain affects 40 of women at some
  point in their reproductive life
• In the U.S. and Europe, CPP is responsible for as
  many as 10 of all gynecological visits and
  one-quarter of hysterectomies
• In nearly half of all cases no medical
  explanation can be found
• Abuse victims have much higher rates of CPP, and
  severity of symptoms tracks severity of abuse

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Screening for Violence in Pregnancy

• 25yo, G1, 14 weeks
• Planned pregnancy
• Healthy, normal A/N course
• Difficulty sleeping
• Husband answers all questions
• Looks down to the floor
• Nervous smile
• What do we screen for in pregnancy?

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Screening in Pregnancy

• Smoking
• Drugs/Alcohol
• Nutrition
• Domestic Violence
• Breast/Thyroid
• Infections
• Cytology

• Anomalies
• Aneuploidy
• Hypertension
• GDM
• Preterm Labor

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Female Genital Mutilation

• Why Mum? Why did you let them do this to me?
• Those words continue to haunt me.
• Its now four years after the operation and my
  children continue to suffer from its effects.
  How long must I live with the pain that society
  imposed on me and my children? - -
• Gambia, Female Genital Mutilation
• A Call for Global Action

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Dimensions of the Problem

• About 2 million girls undergo female genital
  mutilation each year
• At least 90 of women have undergone the
  operation in Djibouti, Egypt, Mali, Eritrea,
  Sierra Leone and Somalia

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Addressing Violence Against Women in the Community

• Sensitize communities to violence against women
  and its impact on women, families, and
  communities
• Encourage men and women to discuss womens
  position in society and how violence is accepted,
  condoned, or even encouraged
• Provide men and women with tools to communicate
  effectively and address causes of violence

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Addressing Violence Against Women

• The responsibility to end violence against women
  rests with individuals, families, communities,
  and governments.
• Governments obligations include
• Repealing laws that condone violence or
  discrimination against women
• Creating stronger laws and effective enforcement
  mechanisms to prohibit and punish violence
  against women
• Making appropriate and confidential services
  available to survivors of violence
• Laws that impede womens equal access to
  resources, power and expression promote
  inequality and foster violence.

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Violence Against Women and Womens Lives

• Expanding the Conceptual Frame

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In Canada
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Epidemiology

• What is the prevalence of violence against women
  in pregnancy?
• 6 (CMAJ 93, 99)
• What percentage of violence against women cases
  in pregnancy are RECOGNIZED?
• lt3

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Epidemiology

• gt90 of victims are women
• Physical, emotional, sexual, financial,
  religious
• 1994 Stats Canada
• 2.5 million women assaulted by partner
• Women are 9x more likely to be killed by a spouse
  than a stranger
• ½ have a history of domestic violence
• Consider partner AND family AND friends AND
  isolation AND resources

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Violence Against Women and Pregnancy

• What happens to victims who experience violence
  in pregnancy?
• 64 escalates/more severe
• What happens to victims of violence post-partum?
• 3 months escalates (breastfeeding, sex, money)
• Describe the cycle of violence
• Tension building/explosive event/remorse

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Violence Against Women and Pregnancy

• What pregnancy complications are associated with
  violence against women?
• Late entry/no entry into prenatal care
• Physical injury to mom/fetus
• ICH
• Gunshots
• PTL/LBW/SA/IUFD/Abruption
• LD

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Violence Against Women and Pregnancy

• What other complications are associated with
  violence against women?
• Self-esteem
• Anxiety/depression/suicide
• Substance abuse (65)
• Chronic illness
• Effect on children witnessing violence
• Aggressive/antisocial/depression/anxiety
• transgenerational abuse
• Economic

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Screening

• Under-recognized
• Present 11x before abuse recognized
• Only 125 ER abuse cases are recognized
• Women hit an average of 30x before reports to
  police
• lt10 of FD/OBs screen (SOGC 1999)

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In all Countries
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Screening

• What/How do you ask?
• Universal/Private/Personal/Multiple
• How do you and your partner resolve
  disagreements?
• Have you been hit by anyone in the last year?
• Are you afraid of your partner?
• S(spousal relationship), A(arguing), F(fights),
  E(emergency plan)
• Alpha Tool (antenatal psych health assessment)
• Warning sign partner answers too many questions

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Offering Support

• What do you do if someone says yes?
• Validate
• Blame/criminal/escalates/cycle/effect on children
• Do not challenge partner!
• Referrals/resources
• Social work
• Safety planning
• Documentation
• Photos, direct questions
• Ongoing support and follow-up
• Avoid medicating

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Provider Responses Avoiding Painful Feelings

• Fear of being overwhelmed
• Reluctance to identify with victim
• Helplessness and inadequacy if cant fix
• Anger and frustration with woman for not
  responding to our needs
• Avoid, dismiss, blame, label, control
• When competence is tied to mastery and control.

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Clinician Responses

• Competence tied to mastery and control
• Trained to diagnose and treat
• Frustration with patient when cant fix
• Blame patient for not meeting clinician needs to
  do a good job
• Distance through avoiding, judging, labeling,
  pathologizing

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Need to maintain power and control
Need to protect against feelings that arise when
we cannot
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Professional Obstacles

• Lack of awareness
• Lack of training and skills
• Lack of peer and institutional support
• Limited community resources
• Limited definition of role
• Limits of medical module

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Structural Barriers for Clinicians

• Time constraints
• Capitation agreements
• Intrusive micro-management
• Diagnosis-driven reimbursement system
• Mandatory reporting
• Insurance discrimination
• Abusers control of health insurance

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Why do they stay?

• Fears not being believed
• Hopeful it will improve
• She is at fault
• Helplessness
• Scared for children
• Pressured by family
• Self-esteem
• Limited resources
• STAYING IS NOT ACCEPTANCE OF ABUSE!

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Violence Against Women

• Empower Education Program Highlights
• With references and material from the Physicians
  Health Network

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Empower Education Program is a 4 Module program
for specialists, GP/FMs, residents, nurses,
social workers and allied professionals

• 1 Why is Violence Against Women an Important
  Health Issue?
• 2 Facilitating Disclosure
• 3 What to do on disclosure
• 4 Next Steps

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Learning Objectives

• Recognize abuse as a social problem with serious
  health consequences
• Identify abused women
• Intervene appropriately
• Make the appropriate referrals

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GOALS

• Decline in morbidity and mortality
• Improved awareness of the health consequences of
  abuse
• Improved recognition and appropriate eradication
  of abuse
• Decline in health professional frustration with
  difficult patients
• Prevention of inappropriate use of medical
  resources
• Reduction in financial drain on health care
  resources

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Highlights of Educational Methodology

• Small group
• Interactive
• Interdisciplinary
• Multi-media
• Peer teaching model
• Emotionally challenging

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Endorsements

• Society of Obstetricians Gynaecologists of
  Canada
• Canadian Psychiatric Association
• Federation of Medical Women of Canada
• College of Family Physicians of Canada

• Royal College of Physicians and Surgeons
• Canadian Obstetrical Gynecological Neonatal
  Nurses
• Assn. of Women's Health Obstetrics Neonatal
  Nurses
• Canadian Nurses Assn.

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Violence Against Women Empower Education Program

• Module One
• Why is
• Violence Against Women
• an Important Health Issue?

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Abuse hurts

• In Canada
• 1 million Canadian women are battered each year
• 25-50 of children in abusive homes are
  abused/neglected
• 60-80 of abused women/abusive men are children
  of abusive homes Sources Macleod L.
  Canadian Advisory Council on the Status of
  Women, 1987. J SOGC 1996 18803-807

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Abuse hurts

• In Canada
• 25 of women report being physically assaulted by
  a current or former partner
• 65 of victims are assaulted more than once
• 32 are assaulted more than 11 times
• 45 of wife assault incidents result in
  injury Source Violence Against Women The
  Hidden Health Burden. World Bank Discussion
  Papers, Number 255, 1994.

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ABUSE KILLS/ABUSE HURTS

• Woman abuse is not a new phenomenon. It has its
  roots in archaic legal practices and old
  religious beliefs. The term rule of thumb is
  derived from British Common Law and describes the
  width of a rod that could be used to beat a wife.
• There are social taboos against discussing
  private matters in public
• Women have personal/emotional reasons for
  remaining with abusive partner

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ABUSE KILLS/ABUSE HURTS

• Woman abuse is an expression of deeply entrenched
  societal beliefs and attitudes about the roles of
  women, men, and violence in our culture
• Woman abuse continues because of all societal,
  religious, economic, cultural, and personal
  reasons

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POWER

• Want to have power and control over partner
• Believe that men have the right to control women
• Believe in resolving conflicts through physical
  means
• Perceive no disincentive in beating partner
• Feel powerless
• Feel unable to deal with personal problems
• Feel that battering is tolerated by society
• Suffer from effects of abuse (witnessed abuse/may
  have been abused)

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Power and Control Wheel

• Relationships in which abuse occurs are based on
  one partners need for power and control. The
  power and control wheel describes ways in which
  abusers can take power and control. The different
  forms of abuse are
• Physical abuse
• Sexual abuse
• Emotional abuse
• Psychological abuse
• Financial abuse

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Equality Wheel

• The other side of the power and control wheel is
  the non-violence or equality wheel. This wheel
  describes healthy relationships.
• These include
• Respect
• Trust and support
• Honesty and accountability
• Responsible parenting
• Shared responsibility
• Economic partnership
• Negotiations and fairness
• Non-threatening behavior

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Environment for Disclosure

• Health professionals need to create an
  environment that encourages disclosure
• Health professionals need to know the right
  questions to ask
• Health professionals need to give the message to
  women that they are capable of dealing with
  seemingly taboo subjects
• Good areas to place information are in the
  waiting rooms and each private room

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Environment for Disclosure

• Health professionals must educate their staff on
  signs of abuse and legal issues
• Health professionals need to remain
  non-judgmental and relaxed
• Health professionals need to provide a safe and
  private space for their patient
• Some women may be afraid to take handbooks,
  usually because they fear the batterer may find
  it. Give her a business-sized card instead.

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Barriers to Disclosure

• An abused womans willingness to take action may
  be hindered by a variety of factors including
• A tendency to minimize the abusive relationship
• Cultural/ethnic/religious beliefs
• Fear of reprisal
• Shame
• Belief that the abuse is deserved
• Belief that she will be blamed

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Barriers to Disclosure continued

• Belief that abuse is not serious
• Belief that he will change
• Financial dependence
• Concern about the children
• Previous negative experience with attempts to
  disclose

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Case Discussion

• Mrs. M.G., a 23 year old female, presents to the
  office for a check-up.
• You ask her direct questions about abuse.

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• What if she says YES?

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If she says YES, your responses could be

• How are you coping?
• How can I help you?
• Have you spoken to anyone about this before?
• Did this happen recently or in the past?

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• What if she says NO?

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If she says NO,

• Accept the response - she may not feel safe to
  disclose
• She may not define her partners behavior as
  abusive
• NO could mean no

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The NO Answer

• A NO answer could also mean that
• She blames herself for the abuse
• She feels that she has failed
• She fears rejection by family and friends
• She feels ashamed

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The NO Answer

• A NO answer could also mean that
• She feels that she will not be abused again
• She fears reprisal and escalation of abuse
• She believes no viable alternative exists
• She is unaware of community resources

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Violence Against Women Empower Education Program

• Module Two
• Facilitating Disclosure

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Asking effectively requiresdealing with the
following issues first

• Being aware of ones own behaviors and attitudes
  toward abuse
• Creating an environment for disclosure
• Creating a safe environment
• Recognizing the barriers to disclosure
• Knowing the right questions to ask
• Developing the skills to deal with the
  disclosure

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The importance of asking

• Sensitive questioning communicates to women
  that
• Abuse is a health issue
• The problem is not too irrelevant, insignificant,
  shameful, or deviant to talk about
• Their discomfort and reactions are
  understandable
• The situation is not hopeless
• They are not to blame

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Other Behavior Clues When Partner is Present,
She May

• Appear afraid of her partner
• Minimize injuries
• Turn to her partner for answers
• Ask her partners permission to speak
• Be unable to make eye contact when explaining her
  injuries

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He May

• Refuse to leave her side and be unwilling to
  allow a private interview
• Speak for the woman/belittle what she says
• Be verbally abusive to others
• Be over-solicitous with health care workers
• Give the appearance of being a nice guy
• Show evidence that his partner fought back (i.e.
  facial scratches)
• Be manipulative, vague or evasive when asked
  about injuries
• Minimize injuries

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Once the Abuse is Disclosed

• For a woman in immediate danger of further
  violence, a safety plan should be developed
  collaboratively to allow her to escape or avoid
  the next episode of abuse. The safety of children
  should also be taken into consideration.

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Once the Abuse is Disclosed

• Once the abuse has been disclosed, the following
  information will be needed to help the woman
  develop immediate and long range plans
• Social history
• Current level of danger
• Existing resources
• The womans plan/agenda
• Her priorities

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Support

• Following disclosure, the health professional
  should state clearly that abuse is not acceptable
  behavior and that the woman is in no way to blame
  for the situation

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Violence Against Women Empower Education Program

• Module Three
• What to do on Disclosure

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Our goals following disclosure are to

• Provide clinical care
• Offer emotional support
• Assess safety
• Document the abuse
• Provide information on community resources
  (shelter services, legal services, etc.)

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Clinical Care

• The following may be indicative of abuse
• Injuries at different stages of healing
• Injuries inconsistent with history
• Multiple injury sites
• High anxiety/depression/panic
• Substance abuse
• Alcoholism
• Non-compliance with treatment plan

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Clinical Care

• Many battered women suffer from recurring
  physical symptoms such as
• Headaches
• Chest pain
• Heart palpitations
• Dyspareunia
• Pelvic pain
• Numbness and tingling
• Nervousness
• Gastrointestinal complaints

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Clinical Care

• Emotional Support
• A woman may feel ashamed of having been beaten
  and of her feelings of powerlessness
• She may be afraid that talking about the abuse
  will lead to more severe beatings
• She may have feelings of helplessness about her
  situation, especially if she was unsuccessful in
  earlier attempts to stop the abuse
• She may feel responsible for the abuse
• She may feel guilt about reporting her partner

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Clinical Care

• Emotional Support continued
• Immediate care includes both permission giving
  and information giving
• Specifically, it is important that you validate
  the womans experience by acknowledging that
  abuse is unacceptable
• She should be told that she has a right to be
  angry, hurt and confused
• She should be told that she has a right to be
  safe
• She should be given information about safety
  planning

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Clinical Care

• The following statements will help to validate
• the womans experience
• You do not deserve to be treated this way
• This is not happening because of anything you
  did
• You are not to blame
• What happened to you is a crime
• Help is available to you
• You are not alone

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Tips on Assessing Safety Following Disclosure

• The following questions may be used to assess
  safety
• Has your partner ever threatened to kill you,
  your children, your relatives or himself?
• Does he have access to weapons?
• Does your partner abuse alcohol or use drugs?
• Is your partner violent outside the home?
• Does your partner hurt the family pets?
• Has the violence increased in frequency or
  severity over the past year?

86
SAFETY

• Options for the woman who appears to be
• IN IMMEDIATE DANGER
• With the womans consent, refer to police/RCMP
• Stay with a friend
• Shelter
• Safety Plan

87
SAFETY

• Options for the woman who appears to be
• NOT IN IMMEDIATE DANGER
• Social worker referral
• Refer to Psychologist/Counselor
• Return to partner/Community Resources
• Safety plan

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Violence Against Women Empower Education Program

• Module Four
• Follow up

89
Referrals whats available

• Health professionals should be aware of the
  resources in their area or be able to refer the
  woman to someone who does. Individual communities
  may have some or all of the following resources
• Womens shelters
• Crisis Centres
• Rape Crisis Centres
• Legal Services
• Program for Partners who Batter
• Support Group
• Individual Counseling

90
Continuing Health Education

• Health professionals should continue to develop
  sensitivity to the issue of abuse. They should
  continue their training/education in
• Screening for abuse
• Interviewing
• Safety planning
• Community resources

91
Referral options

• Leaves home Returns home
• Crisis services
• Friend Family Hotel . Information brochures
• . Community resources
• Shelter Individual
  counseling
• Local services
• Support groups Program for
• partners who
• batter

92
WE CAN..

• Remember to inquire about abuse
• Ask respectfully and non-judgmentally
• Document our findings
• Assess safety
• Refer to community resources

93
What We Can Do

• What We Can Do
• Ask
• Listen
• Validate
• Offer perspective
• Access resources
• Encourage choice
• Ongoing support and prevention

• What That Requires
• Knowledge, skill, and understanding
• Professional and institutional support
• A Violence Against Women advocacy and
  collaboration
• Activism, change social norms

94
Challenges

• Outcomes measurement
• Continued funding
• Preaching to the converted
• Denial
• Interdisciplinary issues
• Integrating community resources

95
Thinking across BoundariesPooling our Resources
for Change
Shared Vision, Shared Strategies
96
SOGC

• Role of physician
• To be aware
• To be approachable
• To identify problems
• To provide support and medical care