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SOGCs Violence Against Women Program


'I think that if the wife is guilty, the husband has the right to hit her...If I ... 3 months: escalates (breastfeeding, sex, money) Describe the cycle' of violence ... – PowerPoint PPT presentation

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Title: SOGCs Violence Against Women Program

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

Society of Obstetricians and Gynaecologists of
  • 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
  • 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.

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

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

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

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

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

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

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

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)

Gender and Violence
  • Violence against women is deeply rooted in male
  • female gender roles in society and in individual
  • 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

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
  • 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

Abusers Control of Health Care
  • Controls medication
  • Controls appointments
  • Controls finances
  • Controls information
  • Controls sleep, food and basic functions
  • Controls legal process

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

Violence Against Women Mental Health
  • Depression
  • Panic Disorder
  • Eating Disorder
  • Dissociative Disorder
  • Substance Abuse
  • Psychotic Episodes
  • Acute and Post Traumatic Stress

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

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
  • Khan, 1996

  • 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

Violence Increases Risk for Other Gynecological
  • A history of sexual violence has been
  • associated with
  • Vaginal bleeding
  • Vaginal discharge
  • Painful menstruation
  • Sexual dysfunction
  • Pelvic inflammatory disease
  • Painful intercourse

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

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?

Screening in Pregnancy
  • Smoking
  • Drugs/Alcohol
  • Nutrition
  • Domestic Violence
  • Breast/Thyroid
  • Infections
  • Cytology
  • Anomalies
  • Aneuploidy
  • Hypertension
  • GDM
  • Preterm Labor

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

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

Addressing Violence Against Women in the Community
  • Sensitize communities to violence against women
    and its impact on women, families, and
  • 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

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.

Violence Against Women and Womens Lives
  • Expanding the Conceptual Frame

In Canada
  • 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

  • gt90 of victims are women
  • Physical, emotional, sexual, financial,
  • 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

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

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

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

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

In all Countries
  • What/How do you ask?
  • Universal/Private/Personal/Multiple
  • How do you and your partner resolve
  • 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

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

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.

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,

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

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

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

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

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

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

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

Highlights of Educational Methodology
  • Small group
  • Interactive
  • Interdisciplinary
  • Multi-media
  • Peer teaching model
  • Emotionally challenging

  • Society of Obstetricians Gynaecologists of
  • 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
  • Assn. of Women's Health Obstetrics Neonatal
  • Canadian Nurses Assn.

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

Abuse hurts
  • In Canada
  • 1 million Canadian women are battered each year
  • 25-50 of children in abusive homes are
  • 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

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.

  • 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

  • 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

  • Want to have power and control over partner
  • Believe that men have the right to control women
  • Believe in resolving conflicts through physical
  • 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)

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

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

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

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.

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

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

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.

  • What if she says YES?

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?

  • What if she says NO?

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

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

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

Violence Against Women Empower Education Program
  • Module Two
  • Facilitating Disclosure

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

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

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

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

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.

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

  • 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

Violence Against Women Empower Education Program
  • Module Three
  • What to do on Disclosure

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.)

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

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

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

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
  • She should be given information about safety

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
  • You are not to blame
  • What happened to you is a crime
  • Help is available to you
  • You are not alone

Tips on Assessing Safety Following Disclosure
  • The following questions may be used to assess
  • 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?

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

  • Options for the woman who appears to be
  • Social worker referral
  • Refer to Psychologist/Counselor
  • Return to partner/Community Resources
  • Safety plan

Violence Against Women Empower Education Program
  • Module Four
  • Follow up

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

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

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

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

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
  • Activism, change social norms

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

Thinking across BoundariesPooling our Resources
for Change
Shared Vision, Shared Strategies
  • Role of physician
  • To be aware
  • To be approachable
  • To identify problems
  • To provide support and medical care