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A Practical Approach toGender-Based Violence:

A Programme Guide forHealth Care Providers and Managers

New York

ACKNOWLEDGEMENTS

This Programme Guide was written by Lynne Stevens, an educator andpsychotherapist, who has expertise in Gender-Based Violence. The writing of thisprogramme guide involved the collaboration of UNFPA and UNIFEM and supportand input from the Gender-Based Violence Group at UNFPA (France Donnay,Maria Jose Alcala, Christina Bierring, Abubakar Dungus, Eriko Hibi, Talat Jafri,Sahir Abdul Hadi, Jaime Nadal-Roig, Annemieke de los Santos, and GiuliaVallese). Miriam Jato, Faiza Benhadid, Laura Laski and Nicola Jones fromUNFPA made useful suggestions and provided additional information as did thegroup from the Country Technical Service Team in Dakar: Bintou Sanogoh,Diana Lima Handem, Laurent Assogba, Soulimane Baro and Richard DackmanNgatchou. Roxanna Carrillo, Ana Flavia d'Oliveria, Monica O'Connor, RuthHayward, Andre Lalonde and Claudia Garcia Moreno's comments added to thequality of the guide. We thank Rema Venu for her editorial support. We also wantto recognise the women who have spoken about their experiences of GBV overthe years and we thank them for helping to shape the ideas incorporated into thisprogramme guide. Finally, we would like to acknowledge The Ford Foundation’ssupport for the preparation and publication of this programme guide.

Foreword

In 1998, UNFPA published a Programme Advisory Note, Reproductive HealthEffects of Gender-Based Violence, which described the serious long-term effectsof gender-based violence (GBV). It also identified a number of strategic entrypoints where UNFPA could begin work on the problem of GBV. One strongrecommendation was that reproductive health (RH) services integrate thetreatment of GBV into their services. As mentioned in the State of the WorldPopulation, Lives Together, Worlds Apart in a Time of Change 2000. GBV is aserious impediment to women's reproductive health, and a violation of basichuman rights.

We know that a sizeable proportion of women, worldwide, have experiencedGBV. However, many women will not mention violence unless asked directly.Yet, few health care providers have been trained to address these difficult issueswith their clients and few clinics have activities that specifically address theneeds of victims of GBV. Women suffer in silence for lack of someone they cantrust with whom they could discuss the violence in their lives – someone whocould listen sensitively and give a helpful response.

To help break this silence we are embarking on an innovative strategy to assistvictims of violence by integrating the assessment and treatment of GBV into RHservices. RH facilities are an ideal place for such activities, since these arefacilities where many women already go, and where they talk about their lives.

A Practical Approach to Gender-based Violence: A Programme Guide for HealthCare Providers and Managers, offers step-by-step guidance on how RH facilitiescan begin their own GBV projects. Three project options are presented in thisProgramme Guide.

Ø Project A involves displaying material about GBV (including information aboutwhere women can get help) in the public and private rooms of the facility.

Ø Project B includes displaying GBV material and also asking all clients aboutGBV. If clients say that they have experienced GBV, they are then referred toan outside group that provides the necessary care and support.

Ø Project C includes all of the activities of Projects A & B, and also offers on-sitetreatment for survivors of GBV.

These project models allow a facility to choose the one that will best fit theirphysical plant, financial and referral resources and capability. The ProgrammeGuide also helps prepare the facility by guiding the clinic through the differentpractical steps needed to integrate their particular GBV project choice into theirexisting activities. The Projects are modular, and a facility may begin with ProjectA and later expand it into B or C.

UNFPA is very pleased and proud to be inaugurating this practical approach torecognising and helping women who are victims of gender-based violence. Weknow that women's lives can start to change when they are given permission tospeak about the violence in their lives and are offered sensitive care andassistance. This can then allow them to take the first steps to begin to heal fromthe effects of the abuse.

Mari Simonen, Director Technical Support Division

TABLE OF CONTENTS

Chapter 1. Executive Summary...................................................................................1

Chapter 2. Introduction................................................................................................4

Chapter 3. Definitions ..................................................................................................9

Chapter 4. Gender-Based Violence and Reproductive and Sexual Health .........12

Chapter 5. The Importance of Asking Clients about GBV.....................................14

Chapter 6. Barriers to Talking about GBV...............................................................17

Chapter 7. Choosing a Project Design ....................................................................22

Chapter 8. Role of the Facility and Staff ..................................................................25

Chapter 9. Starting Your GBV Project .....................................................................30

Chapter 10. Appendices ..............................................................................................43

References ...............................................................................................66

Sample of a Smart Card…………………………………………………… 68

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A Practical Approach to Gender-Based Violence:A Programme Guide for Health Care Providers and Managers

Executive Summary

Until recently gender-based violence(GBV) was viewed as a private orfamily matter. However, there has beena shift in thinking in the last few yearsabout this topic and it is now viewed asboth a public health problem and ahuman rights violation. Numerousstudies have been published thatdocument the prevalence of GBV andits serious effects on women. Fromthese studies we know that one out ofevery three women have experiencedGBV (Heise, Ellsberg & Gottemoeller,1999). Women's groups have spokenout about GBV and have advocated forviewing GBV as a societal problemrather than a private matter.Legislators have been lobbied to enactand implement laws that criminaliseGBV. Global conferences have passedresolutions condemning GBV. TheUnited Nations has defined it andrecognised it as a problem that effectsindividuals, families, communities andnations.

Yet, with all this progress what hasbeen missing is a lack of co-ordinatedservices for the victims of GBV.Although women who go to health carefacilities often have symptoms relatedto GBV, they are generally not askedabout GBV in their lives. Thus, inreproductive health settings victims of

GBV are often the women who arelabelled (and further stigmatised) as“difficult” clients. These victims areconsidered “failures” because theyoften do not use the family planningmethods prescribed to them, do notfollow behavioural or healthrecommendations, fail to return forfollow-up visits and fail to get treatmentfor their STDs. Their symptoms mayworsen and/or they may continue tosuffer from the same symptoms foryears. But the real problem is thatthese women don't get the help thatthey need for what often underlies theirbehaviour and symptoms isundiagnosed GBV. Thus GBV, ifundetected and untreated, can reducethe effectiveness of women's healthcare programmes.

We know that even though health careproviders often do not address GBV,many of their clients are GBV victims.Health care providers see clientssuffering from the effects of the GBVon a daily basis with problems such asundiagnosable, escalating pain,repetitive episodes of STDs, andunintended pregnancies. Faced withsuch problems, staff may feelpowerless, even feel like failuresthemselves because they do not knowwhat to do. Staff may even realise that

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the effects of the GBV are underminingthe services they provide. However,because they are not trained torecognise and address GBV andbecause there is no institutional baseto support them in this area, healthcare providers feel helpless tointervene.

What now needs to be done is to beginto address the effects of GBV on thevictims. In developing countries, a visitto a reproductive health facility may bethe only health care visit that a womanmakes. This visit thus becomes atimely and unique opportunity toassess clients for GBV. Staff,especially those in women's healthsettings such as reproductive andsexual health, maternal child healthand prenatal settings have a criticalrole to play when dealing with victimsof GBV. However, in order for victimsof GBV to talk about the violence intheir lives they first need to trust theirhealth care providers to understandand respond properly to this disclosure.Sensitising staff about GBV is key toincreasing victims' level of trust.

This programme guide addressesthese important gaps in services towomen. The programme guide applieswhat we know about GBV and itseffects and offers a step-by-step guidefor designing and implementing a GBVProject in any part of the world. ThisProject does not have to be one thatoffers victims of GBV everything in theway of services. It can be a modestprogramme which, for example, bothassists victims by educating themabout GBV and gives them a list ofplaces to get help.

The three GBV project options that arepresented in this programme guidethen allow a health facility to choosethe one that will be the best fit, giventheir infrastructure, financial andreferral resources and capability. Theprogramme guide also helps preparethe health facility to begin their Projectby guiding them through the differentpractical steps needed to integrate theirparticular GBV Project choice into theirhealth programme.

Project A involves displaying materialabout GBV (including referralinformation) in the public and privaterooms of the facility. Project B includesdisplaying GBV material and asking allclients about GBV. If clients discloseGBV, they are then referred to anoutside facility that provides thenecessary care and support. Project Cincludes all of the first two but alsooffers on-site treatment for victims ofGBV. The Projects are modular, and afacility may begin with Project A andlater expand it into Project B or C.

Figure 1. Steps for Implementing a GBVProject

• Assessments for choosing the mostappropriate GBV project for their facility

• Development of planning and monitoringtools, GBV material and forms

• Setting up of referral mechanisms,protocols and policies

• Re-routing of clients, continuity of care andfollow-up mechanisms

• Education of staff through sensitisation,training and supervision

• Expansion of staffing and services• Education of the community

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Whichever project a facility chooses, itwill be providing crucial care andservices. Although the project may nothave an impact on the overall level ofGBV in the country, it will serve as aplace where victims of GBV can get thecare they need in an environment thatsupports and validates them.

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Introduction

Although there are many stereotypesabout victims of gender-based violence(GBV), in reality it can happen to anywoman. Victims of GBV can bewealthy or poor, educated or illiterate,and married, widowed or single. TheWorld Health Organization (WHO)estimates that at least one in fivewomen have experienced violence intheir lives (WHO, 1997). Other studiesestimate the statistic to be one in threewomen (Heise et al., 1999). GBV canhave long-term psychological andphysical consequences and effectmany aspects of women's lives.

• Women who have been sexually abused aschildren are at greater risk of havingunprotected sex as adolescents and adultsand therefore at risk for contracting HIV/AIDS(Zierler, Feingold, Laufer, Velentgas,Kantrowitz-Gordon & Mayer, 1991).

• Women who are physically abused havemore unplanned pregnancies than otherwomen (Eby, Campbell, Sullivan & Davidson,1995).

• Many rape victims suffer severe injuriesand/or unconsciousness including mentalillness and death following the rape (Shamin,1985). Rape victims are nine times morelikely than non-victims to have attemptedsuicide (Kilkpatrick & Best, 1990).

The staff at health care facilities oftenknow that they are treating victims ofGBV and they would like to help thesewomen. The question that they oftenask is, "What can we do?" Thisprogramme guide responds to thisquestion by saying that there is muchthat can be done and that health carefacilities are in an ideal position to act.The programme guide offers a map tofollow and this map has three routes.Each facility can choose one of thethree GBV Project options anddepending upon their choice, they willreach a slightly different destination.However, all facilities will be able tooffer some level of services that willhelp victims begin to heal from thetrauma of GBV.

A number of conferences andconventions have addressed physical,mental and sexual violence againstwomen as one of the emerging issues.The Convention on the Elimination ofAll Forms of Discrimination (CEDAW)sets the agenda for a proactiveapproach to women's empowermentand contains specific recommendationsto address violence against women(General Recommendation No. 19,A/47/38, 1992). In addition, GeneralRecommendation No. 24, (A/54/38,May 1999) requires States to prevent

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and impose sanctions for violations ofhuman rights, with particular attentionto gender-based violence, includingsexual abuse. The Programme ofAction (PoA) adopted at theInternational Conference on Populationand Development in 1994 noted that“human sexuality and gender relationsare closely interrelated and togetheraffect the ability of men and women toachieve and maintain sexual healthand manage their reproductive lives.”(Para 7.34). The PoA went on to say:“Violence against women, particularlydomestic violence and rape, iswidespread, and rising numbers ofwomen are at risk from AIDS and othersexually transmitted diseases as aresult of high-risk sexual behaviour onthe part of their partners.” (Para 7.35)The Special Session of the UN GeneralAssembly on the Beijing+5 Review(2000) recognised gender-basedviolence as a crime and recommendedspecific actions to be taken inter aliawithin the judicial and health systems inparagraphs 103a-103i.

In addition, a variety of reports havebeen published documenting anddiscussing GBV including theProgramme Advisory Note on GBV,Reproductive Health Effects of GBV:Policy and Programme Implicationspublished by UNFPA in 1998. In 2000,the UNFPA published the State of theWorld Population. Lives Together,Worlds Apart: Men and Women in aTime of Change recognising GBV asboth a public health concern andviolation of human rights plus animpediment to women's reproductivehealth. Although there are not yetstudies from as wide a group ofcountries as we would like, the data wedo have has expanded our awareness

of this problem and documented themagnitude of the problem and theextent to which victims can be affectedby GBV. Yet, there has been a gap inapplying this information and using it tocreate programmes that addressvictims of GBV. Specifically, what hasbeen missing is the guidance that canhelp people apply this knowledge in apractical manner to help victims ofGBV. This programme guide hopes tofill this gap, complementing what wealready know about GBV, with the goalof assisting health care facilities instarting their own GBV services. Theobjectives of this guide are to provideguidance, support and information onwhat facilities can offer victims of GBVin terms of mainstreaming GBVservices into their programmes.

Although there are many types ofgender-based violence, thisprogramme guide’s focus will be on thethree most common forms of GBV:adolescent and adult victims ofchildhood sexual abuse, domesticviolence and rape or sexual assault.

This programme guide is addressed todistrict health administrators,managerial teams, health clinic teamsand community advocates. Thesepeople can make a difference inwhether and how GBV is addressed inwomen's health care settings. Staff,especially whether in reproductivehealth, maternal child health, prenataland antenatal settings have a criticalrole to play when dealing with victimsGBV. Studies show that victims of GBVneed to trust their health care providersfor them to be able to tell them aboutthe violence in their lives. Sensitisingthe staff on this topic will help thisbegin to happen.

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Health care providers are the peoplewith whom women already talk to aboutmany intimate matters (Heise, Moore,& Toubia, 1995). Added to this specialrelationship, in developing countries, avisit to a reproductive health facilitymay often be the only health care visitfor a woman. This visit is a uniqueopportunity to assess clients for GBV.

Health care facilities must directlyacknowledge that many women whoattend family planning, prenatal care ormaternal and child health clinics arevictims of GBV and that this is animportant topic to bring up with allfemale clients. Because GBV canhappen to any woman, assessingevery client for GBV is critical. Althoughsome individual staff may have hadtraining in the identification of GBV,they usually have no context to do this,as they have not had the support of aGBV project that was a part of thefacilities' services. Some providers atfacilities are supposed to ask aboutviolence but often they do not. Whenasked about this omission, they statethey are uncomfortable bringing up thistopic, fearful that asking about GBV willantagonise clients or feeling they donot know how to respond if the womananswers "yes.”

Some administrators, when askedabout this, say they fear that if thistopic were opened up, the needs andproblems of the victims wouldoverwhelm the staff. Consequently,they would not be able to complete thework they are already required to do.Nevertheless, there are ways tointegrate this topic into already existingprogrammes without overwhelming thefacility or the staff. Actually, integratingthe assessment of GBV can enhance

other programmes in the facility.Experience has shown that in thecontext of an organised project,including training and support, askingabout GBV can be beneficial to thefacility, staff and clients.

For clients who are victims of GBV,such a project can help end theisolation they have experienced asholders of this secret, lessen orameliorate their guilt and self-blame,and increase their knowledge byeducating them about the connectionsbetween their symptoms and GBV. Allof these interventions assist victims infeeling more in control of their lives,thus empowering them.

For staff, being trained in theassessment and treatment of GBV canadd to their repertoire of skills. It notonly offers them information about GBVbut it also teaches them techniques touse in discussing other sensitive topicswith clients and helps to developinterpersonal skills that can enhanceprovider-client relationships. Suchtraining can thus make a hugedifference, empowering not only theclient but the staff as well.

Some administrators think GBV is sucha complex problem that it would requirean enormous amount of resources totackle GBV at their facility. That is nottrue. A project does not have to offervictims of GBV everything in the way ofservices. It can be a modest project,which for example, assists victims byeducating them about GBV plus offersthem a list of places to get help.

This programme guide is designed toassist you in choosing one of the threeGBV Project options described herein.

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Your group can choose the one thatwill be the best fit, given your particularfacility and capability. This programmeguide helps you conceptualise andactualise your Project. It also helps toprepare your staff for integrating yourGBV Project option into your existingprogramme by guiding them throughthe different practical steps.

Before getting to those concrete steps,the programme guide first helpsreaders understand the connectionsbetween reproductive and sexualhealth and GBV, the myths andbarriers to effectively tackling the topicand ways of overcoming them. Key toany programme that helps victims ofGBV is the need for staff to look at theirown responses, beliefs and biasesabout GBV. The section on myths andbarriers covers some of these.Additional ones can be discussed atstaff sensitisation and trainingsessions.

This is a programme guide aboutproviding services. Part of knowing ifyou are meeting the objectives of theseservices is to develop a monitoring andevaluation plan. The researchquestions that you will answer whiledeveloping your project will inform youfurther about the problem of GBV in thepopulation you serve. While someproblems outlined in this programmeguide can be addressed internally atthe facility level, others may requireoutside assistance. For instance, if thestaff is to be trained to assess,intervene, and refer GBV victims, thenthe facility would need to find a personwho is knowledgeable about GBV andcan offer the clinical staff theappropriate training and/or work as aconsultant.

This programme guide includes sampleforms that can be adapted to yourparticular facility, project choice, cultureand language. Chapter 9 providessample outlines on sensitisation andtraining topics that must be covered forstaff to achieve a level of competence.

Forms in this programme guide can beused to:

• Assess the facility prior to commencingyour GBV Project

• Develop a monitoring and evaluation plan

• Identify referral resources

• Screen clients about GBV

• Document GBV in the client's chart

• Gain an in-depth assessment of theeffects of the GBV

• Summarise data that has been collectedon GBV

This programme guide is writtenprimarily for clinics providingreproductive and sexual health andmaternal child health facilities but it canbe adapted to other types of facilitiesthat treat women, such as public andprivate agencies who are often the firstto act. It is important to remember thatwomen need to get help with theeffects of GBV at whatever facility theyattend.

Chapter 9 discusses the importance ofinvolving men in any discussion of GBVand of providing treatment for men whoabuse women. This programme guide,though, will focus on adolescent andadult women and what they need inorder to begin to heal from theviolence.

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GBV is unfortunately a part of manywomen's lives. Victims of GBV havebeen waiting a long time to have theopportunity to name what hashappened to them and get the help

they need in a supportive environment,with caring people who will listen,support and assist them. Creating yourGBV Project offers victims such aplace.

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Definitions

As stated in the Introduction, thisprogramme guide’s focus will be on thethree most common forms of GBV:adolescent and adult victims ofchildhood sexual abuse, domesticviolence and rape or sexual assault.The definitions of each of these typesof violence as well as an overarchingdefinition of GBV taken from the UnitedNations Assembly are given below.

Gender-based violence includes theword gender because most victims ofinterpersonal violence are women.Violence is directed against womenbecause they are female and haveunequal power in relationships withmen and low status in general in theworld. This lack of power and statusmake women vulnerable to acts ofviolence.

Gender-Based Violence

"Any act of gender-based violence thatresults in, or is likely to result in,physical, sexual or psychological harmor suffering to women, including threatsof such acts, coercion or arbitrarydeprivation of liberty, whether occurringin public or private life." (United NationsDeclaration on Violence AgainstWomen, b.)

The overall goal of the perpetrator ofGBV is to control and dominate. GBVusually involves a pattern of abuse.This is particularly true when theperpetrator knows the victim, which hasbeen documented to be true in themajority of the cases of GBV (Russell,1986). Victims of GBV state that thecloser their relationship with theperpetrator, the more traumatic theyhave experienced the abuse to be(Zierler et al., 1991). The pattern ofabuse can be episodic, recurrent orchronic.

Perpetrators use a number of tacticsas part of the abuse and thus mayabuse the victim not only sexually butalso physically, psychologically andemotionally/verbally. This can haveserious consequences for the victim,causing her physical injury,psychological pain and an on-goinghigh level of fear.

3.1 Childhood Sexual Abuse

WHO defines childhood sexual abuseas "an abuse of power thatencompasses many forms of sexualactivity between a child or adolescent(most often a girl) and an older person,most often a man or older boy known

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to the girl. This activity may bephysically forced, or accomplishedthrough coercive tactics such as offersof money for school fees or threats ofexposure. At times, it may take theform of a breach of trust in which anindividual, who has the confidence ofthe child, uses that trust to securesexual favours.

“Incest, sexual abuse occurring withinthe family, although most oftenperpetrated by a father, stepfather,grandfather, uncle or brother or othermale in a position of family trust, mayalso come from a femalerelative...Incest takes on the addedpsychological dimension of betrayal bya family member who is supposed tocare for and protect the child.” (WHO,1997).

Sexual abuse can involve fondling,masturbation, oral, vaginal or analcontact. It is not necessary for sexualintercourse to occur for it to beconsidered sexual abuse. Sexualabuse is also the use of the child forprostitution, pornography andexhibitionism.

"A general unwillingness toacknowledge the extent of child sexualabuse exists in many societies.Attempts to downplay the prevalenceand nature of child abuse often blamethe victim or the victim's mother for theviolence. Accusations against the childinclude the idea that the child invitesthe abuse or that she imagines it. Themother may be blamed for "causing"the abuse by refusing to have sex withthe abuser, or for "colluding" by notrealising or reporting what was goingon." (WHO, 1997).

3.2 Domestic Violence

Domestic violence is the physical,verbal, emotional, psychological and/orsexual battering of a woman by herpartner or spouse. This type of GBVcan involve the use of threatening orintimidating words and acts, hitting, useof a weapon, rape, imprisonment,financial control, cruelty towards her orother people and things she caresabout and abusive and/or demeaninglanguage.

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Figure 2. Categories of Domestic Violence

Physical Abuse is a pattern of physicalassaults and threats used to control anotherperson. It includes punching, hitting, choking,biting, and throwing objects at a person, kickingand pushing and using a weapon such as a gunor a knife. Physical abuse usually escalatesover time and may end in the woman's death.

Sexual Abuse is the mistreatment or thecontrol of a partner sexually. This can includedemands for sex using coercion or theperformance of certain sexual acts, forcing herto have sex with other people, treating her in asexually derogatory manner and/or insisting onunsafe sex.

Emotional and Verbal Abuse is themistreatment and undermining of a partner'sself-worth. It can include criticism, threats,insults, belittling comments and manipulation onthe part of the batterer.

Psychological Abuse is the use of varioustactics to isolate and undermine a partner's self-esteem causing her to be more dependent onand frightened of the batterer. It can includesuch acts as:• Refusing to allow the woman to work

outside the home• Withholding money or access to money• Isolating her from her family and friends• Threatening to harm people and things she

loves• Constantly checking up on her

Physical abuse need only happenonce. Having experienced a beating,the victim is fearful of a reoccurrence.The batterer may only need to verballythreaten her now or look at her in anintimidating manner to get her to obey.

3.3 Rape or Sexual Assault

Rape is the use of physical force, orthreat of force or emotional coercion, topenetrate an adult woman's vaginal,oral or anal orifices without herconsent. In the majority of cases, theperpetrator is someone the womanknows. Rape can be a one-timeoccurrence or it can be ongoing. It mayalso involve the use of alcohol anddrugs therefore making the victim morevulnerable.

Sexual Assault is non-consensualsexual contact that does not includepenetration.

3.4 Other commonly used terms

Victim and survivor are words usedinterchangeably throughout theprogramme guide to describe a womanwho is now or has in the pastexperienced GBV.

Perpetrator and batterer are wordsused throughout the programme guideto describe a person who abuses awoman. Men make up the majority ofthe people who abuse women andmost of these men know their victims.

Staff and provider are words usedinterchangeably in this programmeguide to denote people who work in ahealth care facility.

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Gender-Based Violence and Reproductive and Sexual Health

Until recently there has been silencesurrounding GBV and so victims ofviolence have not been able to put theirpain into words. But the body “speaks”even if the survivor cannot, and herbody can tell her story even if her voicestill can’t.

Victims have, through their behaviour,indirect ways of telling health careproviders about their GBV experiences.Past or present day GBV can have anenormous effect on behaviour andinterpersonal relationships. Forexample, women who were sexuallyabused as children often feel guilty andshameful about the abuse and blamethemselves. These negative feelingsabout themselves can cause women totake more sexual risks, which makethem more vulnerable to unplannedpregnancy, STDs (including HIV/AIDS)and infertility (Wyatt, Gutherie, &Notgrass, 1992). Studies have shownthat these women are also morevulnerable to re-victimisation asadolescents and as adults,compounding the level of trauma andhealth effects (Wyatt et al., 1992).

Rape victims’ bodies may "speak"through their increased visits to healthcare providers. For rape victims, in theyear following the rape there is more

than a 50% increase in the number ofvisits to health providers (Koss, 1993).Yet, most of these women do notdisclose the sexual trauma to theirproviders, nor do providers ask themabout this.

We know that even though health careproviders may not be addressing GBVwith their clients, they are in realitytreating GBV victims all the time.Victims often present with problemssuch as undiagnosable, escalatingpain, repetitive episodes of STDs orunintended pregnancies. Faced withsuch problems, providers may feelpowerless, sometimes even likefailures, because on a daily basis theysee clients suffering from the effects ofGBV, but they themselves do not knowwhat to do. Furthermore, they mayrealise that the effects of GBV areactually undermining the services theyprovide clients, but because they havenot been trained to recognise oraddress GBV, they feel helpless tointervene.

GBV has many reproductive andsexual health effects. It is important tobe able to recognise these. Figure 3highlights the reproductive, behaviouraland social health effects thatadolescent and adult victims of

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childhood sexual abuse, rape anddomestic violence may experience.

In medical settings, victims are oftenthe women who are considered“difficult” clients. They are oftenlabelled “failures” because they fail to:use family planning methodsprescribed to them, follow behaviouralor health recommendations, return forfollow-up visits and get treatment forany sexually-transmitted diseases.

They may get worse or continue tocomplain of symptoms such as

undiagnosable, escalating pain,headaches, pelvic and back pain andgastrointestinal problems.

What often underlies this type ofbehaviour and these physicalsymptoms is undiagnosed GBV. Thereal problem is that these women donot get the help that they need. ThusGBV, if undetected and untreated, canreduce the effectiveness ofreproductive and sexual healthprogrammes.

Figure 3. Health Effects of Gender-Based Violence

Types of Violence Reproductive, Behavioural and Social Health Effects

Childhood Sexual Abuse

(For adolescent and adult victims)

Gynaecological problems, STDs, HIV/AIDS, early sexualexperiences, early pregnancy, infertility, unprotected sex, unwantedpregnancy, abortion, re-victimisation, high-risk behaviours,substance abuse, suicide, death.

Rape Unwanted pregnancy, abortion, pelvic inflammatory disease,infertility, STDs including HIV/AIDS, suicide, death.

Domestic Violence Poor nutrition, exacerbation of chronic illness, substance abuse,brain trauma, organ damage, partial or permanent disability,chronic pain, unprotected sex, pelvic inflammatory disease,gynaecological problems, low-birth weight, miscarriage, adversepregnancy outcomes, maternal death, suicide, death.

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The Importance of Asking Clients about GBV

Addressing GBV is the first critical stepin getting victims of GBV the help thatthey need in order to begin to heal.Since we know that all women arevulnerable to GBV, asking all womenwho visit the health care facility aboutGBV is crucial.

Most victims will not spontaneouslydisclose that they are victims of GBV.Often they have not told anyone aboutthese experiences. Studies show thatmost victims are never asked aboutGBV by their providers (Mazza,Dennerstein, & Ryan, 1996). Yet, instudies that have asked womenwhether they would, for example,disclose sexual assault to their providerif they were asked about it, 70% said"yes" but only six per cent of thewomen in this study said they had beenasked. Ninety per cent of the womensaid they felt their physicians couldhelp them with problems they wereexperiencing because of the sexualassault (Friedman, Samet, Roberts,Hudlin, & Hans, 1992). Victims reportthat although this disclosure wouldinitially be difficult they would be willingto talk about this, in private, with ahealth care provider who asked themquestions about GBV in a caring, non-judgmental manner. The reality is that

many of these women have beenwaiting a long time to be asked aboutthe violence in their lives.

GBV is a public health issue.Addressing GBV in a health carefacility is one important means ofintervening in this public healthproblem. In this context, the focus forthe assessment, intervention andtreatment of GBV is on secondary andtertiary prevention. This can involvescreening for early intervention(secondary prevention) and interveningto minimise the severity of long-termabuse (tertiary prevention). Health careproviders at women's healthprogrammes see women who are bothat present in violent relationships andwomen who have in the past beenabused. Yet, it is clear that eventhough some clients may no longer beinvolved in violent relationships theymay be still experiencing the long-terms effects. There are also womenwho as children or adolescents weresexually abused and although thisoccurred many years ago, they maystill be experiencing the effects of theearlier trauma. In addition, women whohave been raped do not on their owndisclose this for many years (if ever)yet may be suffering from many

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physical and psychological problemsas a result of the rape.

Talking about such topics as familyplanning, pregnancy, reproductivehealth problems, sexuality concernsand physical symptoms a woman isexperiencing can easily move into adiscussion of GBV. Actually, askingabout GBV can have many benefits.Victims often feel alone and isolated intheir experiences of abuse. Just askingthe client about GBV can be the firststep in her beginning to release thesecrets and shame that she has carriedwith her. Asking the client about GBV isan important intervention. Breaking thesilence about this topic can offer herhope.

Health care providers can open a doorfor the client just by asking questionsabout violence in women’s lives. Somewomen when they answer “yes” willimmediately be able to walk throughthat door. Other women will answer“no” to the questions about GBValthough they are actually victims ofGBV. They need more time and trustin the provider and in the project beforethey can honestly answer thequestions. But that door has beenopened nonetheless, and they may bemore ready to discuss it if questionedagain at a later time. By giving clientswho say “no” the message that theprovider wants to know, the door staysopen.

Health care providers are oftenconcerned about what to do if a womanwere to answer “yes” to their questionsabout GBV. Their actual role is crucialbut limited. The appropriate responsefor the provider is to give the survivorsupport, understanding, validation and

information. The provider does nothave to listen to the whole story. Whatthe provider can do, which is ofenormous importance for women whoanswer “yes”, is to be both sensitiveand non-judgmental.

Providers must be sensitive andnon-judgemental

• When the provider brings up the topic• If the client says “yes”• As they tell the client, for example, that no

one deserves to be hurt and abused• When they educate clients about possible

physical and psychological consequencesthat they may be experiencing

• When referrals are discussed with clients

Clients, who have answered “yes" canthen be seen on-site for an in-depthassessment if this is part of the Projectand can be given an appropriatereferral.

There are additional benefits to askingabout GBV for both providers andprovider-client relations. For example,

• It can deepen the relationshipbetween the client and the provider,making it a more honest and openone.

• The facility can be a place wherethe client feels understood andwhere the client gets the help sheneeds.

• It will allow the client to have moretrust in the provider and the facilityas a whole.

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• It can teach providers new skills byincreasing their ability to raisedifficult topics with clients and talkabout them in a sensitive way.

• Lastly, it can increase the provider’ssense of truly being able to respondto their clients.

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Barriers to Talking about GBV

Many factors have contributed to thesilence that has long surrounded GBV.Many people believe GBV is a “private”matter, one that should not bediscussed publicly. It has certainlybeen seen as improper for outsiders tointervene in or even question violenceperpetrated against women. GBV haseven been rationalised as somethingthat is acceptable, under certainconditions, for men to do to women(Friedman et al., 1992).

Victims of GBV themselves have beensilenced, not only by the perpetrators ofthe violence but also by society. They

are told by society that, for instance,the violence is their fault, that theymust have done something to deserveit, that no one will believe them if theydo tell or else they are frightened intosilence by threats of more harm.

6.1 Effects on the Survivor

Figure 4 shows how the perpetrator'sabuse can effect victims' beliefs aboutthemselves and others, thereby makingit difficult for them to initiate adiscussion about the GBV in their lives.

Figure 4. The Survivor's Experience

What a perpetratorcommunicates to the survivor

The survivor's interpretation ofthis

The effects on thesurvivor

I hit you because I love you This is what love is Confusion, re-victimisation

The abuse is your fault I’m bad and to blame Self-blame, confusion,helplessness

No one will love you like I do Without this person I’m alone forever Dependent, fearful of leaving

This is for your own good Other people know what’s good for me Doubts judgement

You don’t own your body, I do I have no control over what people do tome

Poor boundaries, re-victimisation

No one will believe you if you tell I’m all alone and no one cares Silence

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Despite all these pressures not to tell,victims do want to break the silenceabout the violence in their lives. A fewwomen might be able to speak out ontheir own but most need to be askedabout it. But, unfortunately, providers,even when aware that GBV isoccurring, rarely ask their clients aboutit. The common scenario is an impassewhere two people remain silent aboutGBV, one person afraid to tell and theother person afraid to ask.

6.2 Staff Attitudes about GBV

Figure 5 lists some common attitudesthat administrators, managers andproviders have about GBV. These caninhibit them from addressing this topicand thus stop them from assistingwomen who are victims of GBV.Sensitisation and training plays animportant part in gaining the skillsneeded to get past these barriers inorder to feel a level of comfort aboutaddressing GBV. This chart can laterbe used as a training tool to assist staffin understanding their responses to thistopic.

Breaking down the barriers that stopproviders from talking about GBV iscrucial. Knowing what these barriersare and overcoming them is key tosuccessfully intervening with GBVvictims. Because of their role ashealers, providers are one of the fewpeople in the survivor’s life who are inthe position to identify, assess andtreat GBV. Providers, most importantly,

have the opportunity to heal with theirwords and attitude. Studies show thatvictims of GBV are capable of healingfrom the trauma, and one of the mostimportant parts of this healing is havinganother person name and validate theirexperience in a concerned,knowledgeable manner (Heise et al.,1995). There are many kinds of helpthat a survivor may need, such ascounselling groups, shelter, legal help,etc. But being heard and believed,possibly for the first time, is the crucialbeginning of this process. Without this,she may not be able to take those nexthelp-seeking steps.

6.3 Denial

Denial is a common response to GBV.GBV is an upsetting topic and canbring up feelings in providers that canmake them feel powerless. One waythat people react to experiencing theseemotions is to distance themselves byacting as if it were not occurring. Denialon the provider’s part can cause asurvivor to feel that she is the onlyperson this is happening to or she ismaking it up.

If staff have not been educated, theyoften do not know any other way tohandle these emotions. But withtraining they can better understand thedynamics of GBV and their appropriateroles with victims.

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Figure 5. Staff Members' Barriers to GBV

Defense Myths / Barriers Responses

This only happens in other places in theworld, to other kinds of people.

GBV happens in just about every country, to all kinds ofpeople.

This type of thing does not happen to ourclients.

It happens to women of all races, ethnic groups andclasses.

I don’t want to acknowledge this when I see it. GBV is a difficult topic to approach but with training youwill have the skills to do this well.

Denial

This happened to me and I do not want toadmit it.

It is painful to admit this has happened but you can helpothers and may need to get help for yourself.

It’s a private matter. This is a human rights issue.

It’s not my job. GBV is a public health problem.

No time to do this. Addressing GBV takes a bit more time but may saveproviders time in the future.

If I ask it could cause me legal problems. This is something to look into before beginning the GBVProject.

Victims don’t really want to talk about it. Women do want to talk about the GBV in their lives.

Clients will get upset if asked about GBV. Studies show that clients want to tell their heath careproviders about violence in their lives.

She must have done something to provoke it. No one deserves to be hit or sexually abused.

Rationalisation

There is nothing I can do anyway. There is much that you can do and asking about GBV isthe first step in helping women begin to heal.

This happened in the past and could not beaffecting her now.

The past, especially one that includes GBV, can affectsomeone’s well-being in the present.

Minimisation

She doesn’t have a lot of marks so thiscouldn’t have been too bad.

GBV can cause psychological, health and behaviouraldamage that may not be visible, yet is very serious.

This could never happen to me so it could notbe happening to a woman like me.

GBV can happen to any woman although it is hard tothink about being vulnerable to this.

Identification

I could see why her partner would beat her. Be aware that men and women can identify with theperpetrator.

A woman who is being hit should leave. This is a complex situation and it may actually bedangerous for her to leave. We cannot make thesedecisions for clients.

People get over these things in a short time. Even when the physical bruises go away, the survivor isnot necessarily over the other effects.

Intellectualisation

We only deal with medical problems. GBV is a public health problem. Victims of GBV oftenpresent with physical symptoms such as headaches,pelvic pain, gastrointestinal problems, etc. These aresymptomatic of the underlying problem, GBV.

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Also, research in the United States hasshown that approximately 40% ofhealth care providers report havingexperienced physical and/or sexualabuse at some point in their lives(deLahunta & Tulsky, 1996). Ifproviders who have been victims ofGBV have not disclosed this and havenot gotten the support and help theyneed, it may make it more difficult forthem to then address this topic withtheir clients.

6.4 Rationalisation

Rationalisation occurs because staffdon’t yet know how to intervene withvictims. Providers often do not knowhow to respond to hearing traumaticstories about violence. Although theymay be competent in giving thenecessary medical treatment to awoman who has obvious bruises onher body, they are uncomfortablelooking at and acknowledging thecontext of her injuries.

Providers can find reasons for notaddressing the violence in her life bystating that this is not something theydeal with in their roles. This responsecannot only leave clients feelinghopeless about ever getting any help, italso serves to normalise the abuse toher. Although providers may have tospend a longer amount of time with aclient, asking about and assessingGBV may ultimately save time becausethis woman may not need to repeatedlymake visits to a provider because ofsymptoms related to the GBV. Takingthe time to ask about GBV may in theend also save her life.

6.5 Minimisation

Minimisation serves to take what mayfeel to the staff like an overwhelmingproblem and translate it into somethingthat is minor. The seriousness of theGBV is ignored as is the importantconnection between the victim's pastand the present day physical andpsychological symptoms. Faced withsomeone who minimises their pain andproblems, victims can feel upset andconfused because they may beexperiencing a number of GBV relatedsymptoms but no one is helping themby educating them as to theseconnections.

6.6 Identification

Identification happens when peoplefeel a connection to another personbecause of something they have incommon, such as a shared ethnicity,class background, gender, sibling orderor some other characteristic. It cancause people to feel an immediatebond. But in some circumstances theidentification can feel uncomfortable.So, for instance, if this bond occursbetween a staff member and a clientand then the staff member hears fromthis client a story about a threateningand frightening experience, such as arape or having being sexually abusedas a child, it can have a powerful effecton the staff member. In response tohearing this, the provider may find thats/he then distances her/himself fromthe victim. This response is an attemptto feel safe when listening to storiesabout GBV, stories that cause feelingsof vulnerability.

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Female providers, in particular, mayexperience this identification (althoughmale providers may experienceidentification regarding their partners,daughters, mother, etc). It is frighteningto realise that all women are vulnerableto violence. When this occurs,providers may attempt to find ways todistance themselves from this feelingby, for example, blaming the survivorand finding reasons why the survivordeserved to experience this trauma.This response on the provider’s partcan cause the victim to feel veryisolated and guilty.

Staff members too may find they areidentifying with the perpetrator andneed to be aware of this break in theirempathy toward with the client. If thisbreak were to occur the client mightfeel re-traumatised, what is also called

a second injury, as she is againexperiencing an abusive situation.

6.7 Intellectualisation

Intellectualisation is a defense usedwhen the staff feels uncomfortablebecause the situation seems out ofcontrol to her/him. The provider(trained in the medical model andtaught to "fix" or cure others) thentakes on the role of the “expert” whodiagnoses what is going on and tellsthis woman what she should do. Thisbehaviour leaves little room forlistening to the victim’s experience andwhat she can and cannot do nowregarding the violence (and what mayin actuality be dangerous for her to donow). If this occurs, the client mayactually feel more to blame for the GBVafter such an encounter.

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Choosing a Project Design

Figure 6. Choosing a GBV Project

Project Choices Components to Each GBV Project

Project A • Assess the availability of suitable local programmes to which victims ofGBV can be referred

• Sensitise all staff about GBV

• Develop or purchase materials about GBV

• Give out GBV material including referral information

• Support staff by on-going sensitisation

Project B In addition to what is listed for Project A:

• Train health care providers

• Ask all clients who attend the facility about GBV in their lives

• Document the answers to these questions

• Refer victims of GBV

• Support and supervise staff

Project C In addition to what is listed for Projects A and B:

• Hire new staff or train existing staff to administer the in-depth assessmentform to victims

• Facilitate psychological treatment and other types of care of victims ofGBV by offering external referral and/or on-site treatment

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Programme Examples

The following are examples of groups that have integrated GBV into their healthcare programmes. There are not many of them yet, as this is something that isjust beginning to happen. We hope that in the final version of the programmeguide, after it has been is piloted in a few countries, there will be more examplesto add here.

In Caracas, Venezuela, the Associacion de Planificacion Familiar (PLAFAM),an IPPF/Western Hemisphere Region affiliate gives each client who attends theirreproductive health clinic written material about GBV when they sign in with thereceptionist. Each new client is asked about GBV (childhood sexual abuse, rapeand domestic violence) by the health worker and if a client discloses she is avictim of GBV she is offered an in-depth assessment and a referral. In 2000,PLAFAM won the Sasakawa Health Prize from the World Health Organisation forinnovations in health care for the work they are doing on GBV.

In India, the Family Violence Prevention Fund is working with a hospital inBombay, offering them technical assistance so that women who come to thehospital will be asked about experiences of childhood sexual abuse and domesticviolence. If a woman answers "yes" to any of these questions she is then sent toa trained staff member, who will then assess the client and refer her. If a client isafraid to return home, she is offered the option of staying at the hospital in aspecial area created for victims of violence.

In the Philippines, Project Haven (Hospital Assisted Crisis Intervention forWomen in Violent Environments) located in a hospital in Quezon City provides acrisis center for victims of violence. There are a number of entry points forwomen in this project including the department of obstetrics and gynaecology,the emergency section, different outpatient departments and the counsellingdepartment. Health care providers in the Philippines including midwives, nursesand doctors have been trained to identify and assess domestic violence. Some ofthis training is now integrated into the medical and nursing school curricula.

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In Brazil, women who attend the Medical School Health Centre SamuelPessoa-University of Sao Paulo, which offers reproductive health care (and alsoother primary health care including mental health treatment) are screened fordomestic violence if the staff suspects them of being a victim. If a womandiscloses that she is in an abusive relationship, she then speaks to a staff personwho asks her more questions about the violence and offers her a referral.

In Queensland, Australia, a Domestic Violence Initiative began in 1999.Women at a number of participating sites, which included antenatal care clinics,gynaecology clinics and emergency departments, were screened for domesticviolence. Staff was trained to ask women these questions, counsel them if theyanswered "yes" and offer them a referral. An evaluation of the women served atthese health care facilities showed that 97% of the clients supported the routinescreening for domestic violence.

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Role of the Facility and Staff

In order to successfully integrate GBVinto your programme, certain changesmust be made at the facility level. Theproject your facility chooses will, ofcourse, help you decide what specificchanges need to be implementedfacility-wide and what roles the staffneed to take on in the GBV project.Quality of care issues, which are soimportant, will be mentioned throughoutthis chapter.

8.1 The Facility’s Role

8.1.1 To Advocate, Network and Co-ordinate

It is important to network with othergroups that are also addressing thetopic of GBV. Building coalitions ofdifferent groups that are working on thesame issue can enhance the possibilityof change. This change may need tooccur legislatively so that laws can beimplemented or changed regardingGBV, to get government support forbasic services to assist victims of GBVand/or to create or expand NGOs in thecommunity. Not only can these groupsin the coalition be potential referralsources for the GBV Project, but alsothere is the possibility of cross-referringclients. Working together can also helpto avoid duplication of services to

victims of GBV. These groups may alsohave material that can be used asprototypes for the development of thefacility’s material. In addition, yourproject and these groups may be ableto form a coalition that can worktogether funnelling and exchanginginformation on GBV. There may alsobe local groups that have GBVexpertise and they may be able toassist in you facility's GBVsensitisation.

Changing laws and making sure they are enforcedalso makes it harder:

For a perpetrator to say, “this is normal behaviour,"“this is okay for me to do to my partner,” or

For victims to say, “this is what is supposed tohappen to women,” “no one says this is wrong,” or

For the police to say “your partner can do this toyou,” and “ there is nothing we can do.”

8.1.2 Sensitising the Staff

Creating an environment thatcommunicates to clients that "GBV isdiscussed here" is of primaryimportance. Most clients will not havepreviously experienced such anenvironment and victims may first needto test out whether it really is safe todiscuss what until now they have

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probably never said aloud. It isimportant for the facility to pass thistest. One way to make sure thishappens is to involve the whole staff inthe GBV Project, sensitising them tothis topic and to ways of interactingwith victims of GBV. In addition, thestaff needs to be sensitised to the localcontext of this problem and needs todiscuss the issue. For example: Howis GBV viewed in their community?How do people talk about GBV? Whatare the words or euphemisms peopleuse when they discuss it? What are theunderlying concerns of people aboutGBV? (See Chapter 9 for a samplestaff sensitisation outline.) This willallow staff members to be prepared ifthey are at some point approached bya victim. If staff feel competent todiscuss GBV, this communicates toclients that there really is opennesshere. A facility that is open to the realityof GBV in women’s lives lets victimsknow that they no longer need to besilent about this.

8.1.3 Privacy and Safety for Clients

In order to ask clients about GBV theremust be a private room with a doorwhere these discussions can takeplace. In addition, to facilitate womenfeeling safe disclosing GBV, thereneeds to be a clearly stated clinicpolicy that ensures privacy whenwomen are being asked about GBV.That means that a woman’s partnercannot be allowed in the room whilethis is going on. Only she and theperson asking her about GBV can be inthe room. Asking a victim of domesticviolence about GBV in front of herpartner can put her in danger. Thefacility needs to create such a policy ifthere is not one already. If need be,

this policy can then be explained to thepartner by saying that there is a facilitypolicy that states that each client isseen alone for part of her visit.

In terms of the role of the staff and theambience of the facility, safety forvictims of GBV includes a policy of notmedicalizing or psychologizing theGBV or the victim. Doing otherwisecould feel blaming and cold rather thanunderstanding and caring.

8.1.4 Confidentiality

There can be serious health andwelfare consequences to victims ofGBV if their disclosures of GBV were tobe made public. There needs to be apolicy about confidentiality at the facilitythat is clear to both staff and clients.Just like with other health problemssuch as HIV/AIDS, STDs, etc. this isinformation that needs to remainconfidential and thought through interms of how to avoid breaks ofconfidentiality. So, if there is no lockedcabinet to keep records that includeinformation about GBV, the facilitymust, before implementing Project B orC, think through how they will be ableto ask clients questions about GBV,record their answers and keep thisinformation confidential.

Include in the rationale of whyquestions about GBV are being askedof all clients (just prior to asking themquestions about GBV) a short sentenceabout confidentiality. The level ofconfidentiality at the clinic will no doubteffect her answers to the questionsabout GBV. But to not clarify the levelof confidentiality before asking aboutGBV means possibly betraying thiswoman's trust, something which, if she

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has experienced GBV, has alreadyoccurred. Confidentiality also meansthat clients' responses to the questionsabout GBV must neither be discussedprofessionally in public spaces in theclinic because this then might beoverheard, nor should any of thisconfidential information be gossipedabout amongst staff.

If for any reason, recording the client'spositive answer to the questions aboutGBV in her chart is not possible, it caneffect the facility’s ability to keepaccurate data summaries of the womenwho do disclose GBV. As analternative, it may be possible to justkeep anonymous data (which will offersome statistics on how many clients atthe facility are disclosing GBV) if staff,when asking clients about GBV, recordthis on a common piece of paperwithout putting down any identifyinginformation. This would then limit thecontinuity of care that would allowhealth care providers to be able to seefrom looking in her chart that she was avictim of GBV and therefore follow-upon this by giving her specialised carewhen she returns to the facility.

If it is possible to have confidentialitythen use the documentation stamp,(the sample documentation stamp islocated in Appendix 6) putting thestamp on the inside cover of eachclient's chart for easy access and quickawareness by staff.

8.1.5 Sensitivity to the Person and theProblem

It is also important for staff to beknowledgeable about the laws in theircountry regarding GBV. Thisinformation can be helpful in terms of

understanding the problem and indisseminating this information to clientsat the clinic.

Basic materials in the relevantlanguage, and at different readinglevels need to be available in thewaiting room, consulting rooms andbathrooms, both for women to readthere and take home with them. Avideo monitor in the waiting room canshow tapes about GBV, focusing onboth its effects and solutions. Posterscan adorn the walls with photos andwritten messages communicating toclients that GBV is not acceptable, thatwomen do not deserve this type oftreatment, and it is not the woman’sfault if this does happen. The postersand reading material can present waysthey can get help if they currently areor have in the past been victims ofGBV. Creating a small card for batteredwomen that they can put in their shoeand that contains both educationalinformation as to what kinds ofbehaviours constitute abuse andaddresses and phone numbers ofplaces they can call to get assistance ishelpful. This will allow them to haveimportant information that can behidden from the batterer.

For non-literate women the videos,mentioned above, could assist them, orprinting or purchasing descriptivecomic books and/or hanging up posterswith icons that have a clear messageabout GBV are alternative ways totransmit this information. Also, ifpossible, holding groups in the waitingroom where a staff person couldfacilitate an educational discussionabout GBV in women's lives withclients would be another option for

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educating both non-literate and literatewomen.

8.2 The Staff’s Roles

Most health care providers’ educationand practices are based on a medicalmodel that seeks to diagnose and “fix”clients. But there are other parts tomedical treatment. "The 'practice ofmedicine' can instead be defined as"diagnosing, healing, treating,preventing, prescribing or removingany physical, mental or emotionalailment…of an individual." (CivicResearch Institute, 2000.) The staffneed to learn a different model thatencompasses an understanding of themany psychosocial factors that effectsomeone's life and health, ones suchas culture, gender, family, religion,poverty, drugs and alcohol andeducation. There are many benefits tothis broader model. If providers canuse this model and offer victims whatthey need, i.e., understanding, support,openness and respect, they can trulyoffer victims the help that they need.

With the facility’s support, the staffneed to examine and expand theirroles. The role of the provider withinthis project is to identify and assessGBV and to assist the survivor ingetting the help that she needs to dealwith the effects of the violence. Thestaffs’ specific roles in the GBV Projectare:

8.2.1 To Witness

Most women who have experiencedGBV have never disclosed this toanyone. Having the encouragement todo so now allows them, probably forthe first time, to tell someone about

their private pain. She can now put intowords what has never before beenheard by another human being. Theprovider does not need to hear thewhole story but does need tounderstand the injustice of what theyare hearing and communicate this tothe client. Along with this, the providercan help this woman get the assistanceshe needs.

8.2.2 To Listen and to Validate

Many victims say that the experience ofbeing listened to by the provider is initself very beneficial. (Family ViolencePrevention Fund, 2000). If the survivorresponds affirmatively to the questionsabout GBV, the provider can respond,not with suggestions or prescriptions,but with understanding. The survivorneeds the provider to be supportive byshowing the client empathy, sensitivityand belief in what the client is tellingher/him.

8.2.3 To Educate

When women disclose histories of orpresent day experiences of GBV, theprovider can help educate clients aboutthe connections between theirsymptoms and the GBV, ways they cantake better care of themselves, andvery importantly, that they are notalone. Knowledge is power and thismay be new and important informationfor the survivor as she may never havemade a connection between hersymptoms and the GBV or known ofanyone else who has gone thoughwhat she has gone through.

8.2.4 To Document

When asking clients about GBV it isimportant for the provider who sees her

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to document the answers in the client’schart. Depending upon the projectmodel that has been chosen, thisdocumentation can include enteringinformation into the chart about whattype of GBV she has experienced,when this occurred, filling out the in-depth assessment information, notingwhat referrals were made and, if thereis physical evidence, such as bruisesor scars, filling out a body map. (Thesample documentation stamp inAppendix 6, the in-depth assessment islocated in Appendix 9, and the bodymap is located in Appendix 10).

If there is a confidentiality policy at thefacility and it is possible to documentthe client's answers to the questionsabout GBV, put the GBV stampdocumentation box on the inside coverof each client's chart thereby making itvery visible to any staff member. Theother information about the GBV, suchas the answers to questions about whothe abuser is, forms such as thedanger assessment, and the in-depthassessment could all be put at the backof the chart.

8.2.5 To Support

Providers need to be able to respondappropriately when clients discloseGBV. The provider needs to be non-judgmental, caring and sensitive. Thismeans not telling the client what sheshould do but rather assisting her inthinking through her options and what,if anything, she is ready to do now.Supporting clients means respectingtheir decision-making and believingthat they best know what they need.Clients, after disclosing GBV, may fearthe provider's negative judgement andit would be helpful to let victims know

that they are not being judged but that,for example, the disclosure is a bravegesture on their part.

8.2.6 To Be A Team Member

The provider needs to work with otherstaff at the facility who are alsoinvolved with the client. The staff needsto work as a team by co-ordinating thesurvivor’s care and, after gettingpermission from the client, sharingnecessary information about her.

8.2.7 To Refer

Victims of GBV need to be offeredreferrals to various types of agenciesdepending upon their specific needs.The staff needs to be trained in howand when to make a referral to asurvivor of GBV. Providers must assistclients in getting the services theyneed. Knowledge of what resourcesare available, helping clients connectwith these resources and following-upwith clients on whether they used thereferral, and if so, their feedback aboutthe quality of the referral agency, isimportant.

8.2.8 To Provide Related Services

If the facility offers on-site services -such as psychological counselling,support groups, legal advice andassistance - the staff needs to knowhow victims can access these servicesat the facility, assist them in doing soand have contact with the other staffmembers who treat victims of GBV atthe facility.

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Starting Your GBV Project

There are a number of steps involvedin starting a GBV Project. These arelisted in a certain order in this guidebecause there is a logical progressionto developing and implementing theGBV Project each facility chooses. Forexample, before staff could start askingclients about GBV they would first needto have set up a referral mechanismbecause asking clients about GBVwithout first having agencies to sendvictims to would be unethical and

unprofessional. Some of these stepscan be done simultaneously.

Steps in Project Development andImplementation

As mentioned in the last chapter, theproject you choose will have all orsome of the following steps brieflydescribed below. Project A will havefewer steps, while Projects B and C willhave more steps.

Figure 7. Project Development Guide

Project Type Action

Project A : Steps 1-11

1. Meet with community stakeholders.

2. Assess staff capability

3. Assess financial resources

4. Assess referral services

5. Select type of GBV project

6. Create a work plan

7. Create a monitoring and evaluation plan

8. Set up a referral mechanism

9. Create GBV protocols and policies

10. Sensitise all staff

11. Develop or purchase educational material for clients

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Project Type Action

Project B : Steps 1-17

12. Develop screening forms

13. Modify patient routing

14. Train clinical staff

15. Promote continuity of care and follow-up

16. Provide staff support, supervision and continued training

17. Educate the community

Project C : Steps 1-18 18. Expand staffing and services

9.1 Description of Steps

9.1.1 Meet with Community Stakeholders

It is important to first meet withstakeholders in the community andhave a broad discussion, which couldinclude asking for their input, informingthem of your plans, and getting theirsupport for your project. Participantscould include politicians, local leaders,NGOs, chief of the health district,health ministers, police, religiousleaders and others. Part of the meetingcould focus on finding out how thesecommunity leaders perceive theproblem of GBV and how they seeGBV affecting individuals, families,communities and the nation. Includingthem by soliciting their opinion aboutthis problem is a critical step in terms ofgetting support and backing for yourproject.

It is not necessary to have prevalencedata on GBV occurrence beforemeeting with stakeholders or beforebeginning your project. The immediategoal of each project is to help victims of

GBV heal from the effect of the GBV.Each facility will be able to collect somedata about the prevalence of GBVthrough the implementation of theirprojects.

9.1.2 Assess Staff Capability

Before beginning a GBV project, themanagers at each facility need toassess the level of knowledge that staffat the facility already have about GBV.In addition, they need to find out whatthe staff see as barriers and benefits tobeginning such a project. It would beimportant to assess what has been oris already being done, if anything, atthe facility in terms of addressing GBV.For example, some staff may alreadybe asking clients about GBV on theirown initiative. (The form in Appendix 1can help you with this assessment.)

9.1.3 Assess Financial Resources

Facilities need to look at their financialresources to see what monies areavailable or could be raised in order toimplement a GBV project. There needsto be a matching of the monies

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available with a detailed budget of whateach Project (A, B or C) would cost.This can give the facility an idea ofwhat they can do or at least start outdoing.

Figure 8. Possible Project Expenses

Project A: funds needed for developing referralinformation, educational materials for clients, andfor sensitisation of all staff.

Project B: funds needed for developing referralinformation and developing a referral book,educational materials for clients and staff, newforms, sensitisation of all staff, and for trainingand supervision of providers.

Project C: funds needed for developingeducational material for clients and staff and newforms, sensitisation of all staff, training andsupervision of providers, training of staff toprovide treatment or for hiring new staff, andspace for the on-site GBV treatment.

9.1.4 Assess Referral Services

Finding out what services are availablein your community is crucial. This willtell you what types of resources aremissing. If there are no resources, orcritical ones are missing, then someservices must be developed beforebeginning to actually ask clients aboutGBV. It would not be ethical to askabout GBV, have a client answer "yes"and not be able to offer her help. If acrucial service is not available in thecommunity (e.g., psychologicalcounselling) then the project will needto see that it is provided, perhaps onsite. One way to do this might be totrain staff members or former victims ofGBV so that they can provide theneeded psychological treatment orpsycho-educational support on site.

9.1.5 Select Type of GBV Project

It is important that a GBV Project bechosen, from A-C, which canrealistically be accomplished. Thismeans choosing a Project based oncertain considerations.

Considerations

• The capacity of your staff• The local resources available for referral• The financial status and prospects of your

facility

• The physical infrastructure -- e.g., space forprivate conversations

Groups can also use a modularapproach, starting with Project A, andlater adding other components such asdirectly asking clients about GBV whenthey come to the clinic. When thishappens the project is transformed intoProject B. It is better for each group tobegin with what they can realistically doand be successful at it and then atsome point in the future add on othercomponents.

Some GBV Projects may want to hire aco-ordinator (or choose a staff personwho has an interest in the topic and theability to take on that job) whose job itwould be to oversee all thecomponents of the Project. This co-ordinator would work with the staff onthe actual implementation of theProject, collecting data, organising on-going training and support groups forthe staff and trouble-shooting anyproblems or questions that arise.

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9.1.6 Create a Work Plan

Now that you have assessed yourresources and selected a project type,you should prepare a work plan to helpyou organise your efforts. A basic workplan specifies what has to be done, whowill do it, and when. In this Project, youcan organise your work plan using thesteps that apply to your project type asoutlined in Figure 7. (See Appendix 2 fora sample work plan.)

9.1.7 Create a Monitoring and EvaluationPlan

Monitoring is important, not just so thatyou can demonstrate to others whatyou have accomplished, but also sothat you can judge how the project isprogressing, which components areworking well, and which may needadjusting. (See Appendix 3 for samplemonitoring and evaluation plan.) It iscrucial to plan monitoring andevaluation at the very start of theproject. Otherwise, you may well findthat you don’t have the information thatyou need later on. One way to thinkabout what information you will wantlater is to think about your annual orfinal report on the project. What will youwant to say? What tables might youwant to include? What questions willyou want answers to? Now, how willyou go about collecting the data youneed?

To monitor the activities of your projectyou will need indicators. There are anumber of types of indicators: input,process, output, outcome and impact.These are on a continuum andincrease in terms of levels of difficulty.

Input indicators measure such thingsas supplies, equipment and materialsthat are purchased for the project.

Process indicators measure activitiessuch as training and supervision.

Output indicators record the results ofprocesses, such as number of peopletrained.

Outcome indicators are more generalthan outcome indicators, such asimproved quality of care.

Impact indicators measure theultimate result of the project, such asthe reduction of the effects of the GBVon clients.

For a given activity, such as training,you would like to use a number of kindsof indicators. For example, number oftraining materials purchased (input);training programme developed(process); number of staff trained(output); improved staff knowledge andattitudes (outcome). It is not alwayseither necessary or feasible to measureimpact.

Having a clear work plan will help youdevelop your monitoring and evaluationplan. Under each step of projectdevelopment there will be a number ofactivities. Look at each activity andthink how you will monitorperformance. Remember that in orderfor data to be recorded and collectedstaff have to be assigned these duties,trained to carry them out andsupervised from time to time. Forinstance, if clients are asked aboutGBV and the answers are recordedwho will collect this data each month?

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(See Appendix 11 for a monthly datasummary form.)

In addition to monitoring performanceof particular activities, think aboutbroader questions you may want toanswer about your project, and howyou can answer them. Some questionsand means for answering them arepresented below.

Projects A, B & C

• Was the sensitisation processeffective in increasing staffknowledge and changing attitudes?Conduct pre-sensitisation and post-sensitisation tests.

• Does the staff find the sensitisationprocess useful? Do interviews withstaff 2-3 months after sensitisation.

• Do clients take the materials that aremade available in waiting rooms,etc.? Have a staff person keep track ofmaterials.

• Do clients find the materials useful?Conduct exit interviews with arandom sample of clients, forexample, every 5th or 10th client forone week. (See Appendix 12 forsample exit interview questions.)

Projects B & C

• Is the staff in fact asking clientsabout GBV? Analyse records showingwhether clients were asked about it.

• Is GBV a common problem in yourclient population? This can beanswered by keeping records thatshow what proportion of women whoare asked about it say that they haveexperienced GBV. Show proportionsby type of violence.

• Will at least some victims of GBVdisclose this when asked? Again,analyse clinic records.

• How do women feel about beingasked questions about GBV?Conduct exit interviews with a randomsample of clients (e.g., every 5th or 10th

client for one week). (See Appendix 12for sample exit interview questions.)

• How many women were offeredreferrals for GBV, what kind ofreferrals, and how many acceptedthe referrals? If you want to answerthese questions, staff must record theinformation in the clients' charts andthen the information has to beabstracted from the charts andsummarised.

• Does the staff find the supportsessions useful? Use confidentialevaluation sheets every 3 months.

Project C

• How do clients feel about the newservices? Use confidentialquestionnaires.

• What kinds of GBV services wouldclients like to see added? Conductfocus group discussions with clients.

• Is the psychological treatment beingprovided on site effective in terms ofreducing symptoms? Questionnairesabout symptoms can be given toclients at the start and end oftreatment.

Once you have identified the questionsthat you will want to answer, and theinformation that you will need to do so,the next step is to prepare an overallmonitoring and evaluation plan. Thiswill show for each activity in your work

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plan what indicators you are using,what the sources of data are, who isresponsible for collecting theinformation, and how often it must becollected. (See Appendix 3 for samplemonitoring and evaluation plan.)

Collecting data brings up the topic ofconfidentiality. It is important tosafeguard clients’ confidentiality whenthey answer questions about GBV. Todo this you need to build in ways toprotect clients’ identities, for example,by only using chart numbers whenabstracting data from clients' chartsand keeping the charts in lockeddrawers. If clients' names are kept oncomputers, these files must beprotected so that there is limitedaccess to them.

9.1.8 Set Up Referral Mechanism

In order to implement Projects A, B andC, services for victims of GBV need tobe available in areas such aspsychological, psychosocial support,legal, housing, judicial plus otherpossible services. Some facilities maywant to hire a consultant who couldthen meet with potential referral groupsand evaluate their services. Or, if not aconsultant, then a staff person from thefacility should be given the task ofidentifying and assessing resources.

It is crucial that the people who staffthe referral services have training andexperience in working with victims ofGBV so that women who are referredthere can get the kind of help that theyneed. (See Appendix 4 for a sampleguide on how to evaluate referralsources.)

Once the identification and assessmentprocess of potential referral resourceshas been completed, the facility needsto decide how the staff will access thereferral resources. For Project A, thematerial left in the waiting room andother places will include the contactinformation for the different resourcesso women could, on their own, call orvisit them.

For Projects B and C (in addition toputting out material with referralsources in public and private places), areferral book needs to be created sothat staff can make appropriatereferrals and do so with ease. Thereferral book could be divided up bycategory of referral and under thatcategory each referral resource wouldbe listed on its own page, describingthe services it offers. The contactperson at the facility, fee they charge (ifany), hours they are open, etc., shouldalso be contained on that page.

Everyone at the clinic needs to beaware of where this book is kept andtrained in how to use it. One staffperson could be designated toregularly, twice a year for instance,update the book with new resourcesand edit out ones that no longer existor have been found to provide poorquality of services.

9.1.9 Create Protocol and Policies

In order for GBV to be integrated intowomen's health programmes, thereneeds to be a written protocol statinghow each Project works. The protocolshould start at the point the cliententers the facility. Some questions tocover in a facility-wide protocol are:

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• Will each client who attends thefacility be handed material on GBVor will the materials be left in publicand private spaces? Or both?

• Who will ask clients about GBV?

• What will happen next if a womandiscloses that she is a survivor ofGBV?

• How and where will this bedocumented in her chart?

• Who at the facility will offer victimsof GBV referrals?

The protocol will be a writtendocument. A part of the staff trainingwill be devoted to explaining therationale for the protocol and how it willwork so that everyone is clear. Eachperson at the facility will then knowwhat their role is vis-à-vis the protocoland how to perform that role. Alsocontained in the protocol will beinformation about who the staff can goto if there are problems and questionsin the implementation of the GBVProject.

In terms of policies, two critical onesare those covering confidentiality andprivacy. These were discussed inearlier sections. (See Chapter 8.)

9.1.10 Sensitise All Staff

In order for a Project to succeed, staffmust support it. It is important for thestaff to understand both the reasonsthe GBV Project is being integrated intothe existing programme and theimplications of this for the facility as awhole. Whichever GBV Project ischosen, all staff members need to besensitised. Even if, as in Project A,

material is left in the waiting room forclients, if a client then starts to discusswith the receptionist what they she hasread, that staff person needs to be ableto talk with this client about herquestions, concerns and experiences.

Figure 9. GBV Topics for Sensitising AllStaff

• Rationale for integrating GBV intoreproductive health

• The concept of gender

• Definitions of different types of GBV

• Statistics

• The laws against GBV in your country

• Myths about GBV

• The staf’f’s own beliefs and attitudes aboutGBV

• The connection between RH and GBV

• Why GBV occurs in society

• The hidden nature of the problem

• The effects of GBV on the survivor, herfamily and society

• The dynamics of GBV

• Symptoms that GBV victims manifest

• Barriers to talking about GBV

• How this Project will work

• The staff's roles with victims of GBV

Just like most people, staff havepreconceived beliefs about GBV. It isimportant for the staff to have anopportunity to look at their own biasesand beliefs about this topic. Helpingthem to confront these and changethem is crucial. Dividing people intosmall groups and having themparticipate in exercises that allow themto look at and question their biases canbe very effective.

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Getting people to do role plays aboutGBV -- where each person has theopportunity to play both the providerand the victim -- is a way for the staff tofind out how it feels to be, for example,a battered woman talking to a nurse ordoctor. Role playing a provider alsogives the staff the opportunity topractice asking questions about GBV toclients in a safe environment. This partof the sensitisation is key to thesuccess of the project. Administeringpre- and post-training tests can tell youhow effective the sensitisation hasbeen in terms of both gains inknowledge and changing attitudes.

Sensitisation needs to be done for thewhole staff before the GBV Projectbegins, and then done periodically toupdate staff and introduce thisinformation to new staff.

9.1.11 Develop or Purchase EducationalMaterial for Clients

Each project will need to develop orpurchase the most appropriate GBVmaterial for their client population. Thismaterial may need to be customised tosome degree, especially if you areputting information about referralsources in the materials. (SeeAppendix 14 for the names of someplaces from which to order materials onGBV.)

The minimum amount of material tohave at your facility would includehaving posters about GBV on the walls,short pamphlets or booklets located inthe waiting room, bathroom andexamining rooms, and pocket-sizedcards. These cards could be put in thebathrooms and can, for example, say“You do not deserve to be hit, “ or

could describe different types of GBVand ask women if they areexperiencing any of these. The cardscould also be used to inform womenabout the laws about GBV in thecountry. Other possibilities are pocket-sized cards that educate women onhow to make a safety plan if they are ina domestic violence situation. Anotherpossibility is to include informationabout GBV in the health material that isalready distributed at the facility.

Projects B and C also need to havecards and/or brochures with referralinformation placed in various areas inthe facility. Even though in Projects Band C women will be asked aboutGBV, there are some women who willnot be able to openly answer thesequestions but may be able to, on theirown, take the material and use it atsome point to get assistance. It isimportant to give them this option.

Educational material needs to bewritten in the appropriate language andat a reading level that most clients canunderstand. Looking at materials thatother groups have created can give thestaff ideas. Looking at this can help youdecide what would work best at yourfacility and with your particular clients.Some of this material may be for sale(or be free) and purchasing this cangive the Project the ability to quickly putout good-looking material rather thanhaving to start from the beginning anddevelop their own.

9.1.12 Develop Screening Forms

In Projects B and C clients will beasked directly about GBV in their lives.It is important to ask the samequestions about GBV with every client

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who comes to the facility and todocument the answers to thesequestions in their charts. (There is ascreening protocol in the back of thisprogramme guide in Appendix 5.) Thebriefest documentation form can betransformed into a portable stamp thatcan be stamped on a client’s chart todocument her answers to the questionsabout GBV. (See Appendix 6 for thesample documentation form.)

For Project B, if a client discloses, forexample, that she is being beaten, theprovider needs to find out moreinformation including the level ofdanger she is in presently. And if sheis in danger, the provider must workwith her to make a safety plan. (Seesample forms in Appendices 7 and 8.)

For Project C, if a client discloses thatshe was sexually abused as a child,the next step would be for the client tohave an in-depth assessment (seeAppendix 9). This can be administeredby a psychologist/social worker or astaff member who has had specialisedtraining in GBV. Completing thisassessment form will help the clientand the health professional understandhow the past or present violence isaffecting the client now, if she is inimminent danger, if and how the GBVis affecting her children, and whattypes of on-site services or off-sitereferrals she needs.

9.1.13 Modify Patient Routing

If your programme is adopting ProjectsB or C there needs to be a reworkingand/or clarification of the route clientswill now take as they move through thefacility. This must be worked on beforebeginning the Project.

Questions to be answered include:

• When will the client be asked aboutGBV and what will then happen nextif the client answers “yes” to any ofthe questions about GBV?

• What happens if the client does notdisclose GBV during the intake butrather discloses this to the medicalprovider who, for example, maynotice bruises on her and theninquire about GBV? What thenwould be the next step for theclient? Would she then return to thehealth worker or, if this is Project C,would she go to see thepsychologist/social worker/trainedstaff member? Would she, afterdiscussing the GBV, then return tosee the medical provider?

• In Project C, what if thepsychologist/social worker/ trainedstaff member was not in that day?What would be done for the clientwho disclosed GBV? Would she begiven an appointment to see thepsychologist/social worker/ trainedstaff member on another day?

Thinking these questions throughahead of time will help each GBVProject work more smoothly for boththe clients and the staff. Diagrammingthese different routes as a way oforganising the possible routes and as away to review it with staff is oneconcrete option. Presenting this at theclinical training would then inform staffof the new routing.

9.1.14 Train Clinical Staff

The clinical staff, including healthworkers, doctors and nurses, all musthave in-depth training since they arethe people who have the most direct

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contact with clients and who will beaddressing the topic of GBV with them.They need to feel comfortable andcompetent in order to do this well.

Since most past education and trainingof health care providers has notincluded the topic of GBV, this issomething that they may not feelcomfortable addressing with clients atfirst. The goals of the training are tohelp them get beyond their barriers,understand their role in the project andthe important part they play in assistingwomen victims of GBV. Their roles inthe GBV Project will incude: witness,listener, supporter, educator andvalidator. (See Chapter 8.)

Projects B and C need to locateconsultants who can offer the clinicalstaff an in-depth training (see Figure10). There are now consultants whohave an expertise in this area and whocan be contacted and interviewed tosee if they are suitable. There is alsomaterial available for health carefacilities and their staff to read aboutGBV. (Some of this material is listed inAppendix 14 of this programme guideand some can be found on the Website addresses provided.)

Having a staff library so that providerscan learn not only about the generaltopic of GBV but also about specificissues such as the connection betweenGBV and HIV/AIDS or childhood sexualabuse and its effect on pregnancy,would further assist staff in their work.

9.1.15 Promote Continuity of Care andFollow-up

Clients who have disclosed GBV needto have this documented in their charts.

Having already been trained in theassessment and treatment of victims ofGBV, the provider is aware that GBVmay cause a client, for example, to feelvery uncomfortable taking her clothesoff and/or being touched by someonein an intimate way. He/she will factor inthe GBV into whatever procedure isdone or whatever family planningmethod is decided upon. For example,if a client’s partner is beating her, thepartner may also, as a way ofcontrolling her, not want her to use anymethod of family planning. The clientthough, wanting to have control overher body (and whether she getspregnant), then needs a form of familyplanning that she can use without herpartner knowing about it. It is thereforeimportant that providers factor inpossible GBV into their clients' livesbefore recommending a family planningmethod.

When a staff person sees a client, whoduring her last visit disclosed GBV,s/he needs to make a non-judgmental,empathetic reference to this pastdisclosure. As part of the follow-up, thestaff person will again ask the clientabout GBV in her life and update thisinformation as to whether the GBV isstill going on and how this is presentlyaffecting the client's life. If appropriate,clients will also be offered a referral atthat time. This is important, especiallyfor women who have in the past havedeclined a referral. She may now beready to accept the recommendation ofa referral.

9.1.16 Provide Staff Support, Supervisionand Continued Training

Having a GBV Project integrated intoyour programme is a way to reach

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clients who are victims of GBV. It is notonly important to open this topic up forclients but it must also extend to thestaff. Statistically speaking, there aremost likely members of the staff whoare currently or have in the past beenvictims of violence. They need to knowthat they can get help through the GBVProject too, without experiencingshame or stigma. This is an importantmessage for a number of reasons,including that this particular staffmember may be in danger of beingseriously injured. This disclosure canaffect the quality of the Project. Staffwho have been victims of GBV in thepast and who have never talked aboutthis may be reluctant to bring up thistopic with clients. They may avoidasking clients questions about GBVbecause it makes them uncomfortableand anxious, bringing up memories oftheir own abuse experiences. Just aswith clients, staff members who arevictims of violence can begin to dealwith the effects of the violence in theirown lives if they are clearly given themessage that this is something thatcan and does happen to any womanand that the people they work with arewilling to offer them understanding,support and assistance. It would bebeneficial to all and be a consistentmessage about opening up this topic ifthe GBV Project allowed all employeessuffering the effects of GBV to get thehelp and support they need.

Ongoing training is an importantcomponent in the GBV Project. Thestaff periodically needs to haverefresher trainings plus training on newaspects related to the GBV Project.Staff should periodically be assessed inorder to find out from them what they

see as important topics that should beincluded in the trainings. New staff, ofcourse, needs training on this topic.

Figure 10. Topics for Training of ClinicalStaff

• Understand the benefits to integrating GBVinto the facility’s programme

• Clarify each person’s role at the facility inrelation to the survivor

• Identify the physical and psychologicaleffects and symptoms of GBV

• Recognise the dynamics of GBV• Understand client barriers to disclosing

GBV• Recognise and overcoming staff barriers to

addressing GBV• Discuss providers' concerns about

protecting themselves from retaliatoryviolence

• Learn to directly and indirectly assess asurvivor of GBV

• Learn to ask clients about GBV• Develop a comfort level so as to assist

clients if they answer “yes”• Develop skills to respond if there are

suspicions of GBV but the client answers“no”

• Understand how to document GBV andmaintain confidentiality

• Learn how to make a referral• Discuss the effects this type of project may

have on staff• Gain familiarity with the new forms and

referral book

Another important part of this or anyProject is making sure to take care ofthe staff members who are themselvesin the on-going position of taking careof clients. Listening to stories of

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violence is difficult and can take a tollon them. This is especially true if thestaff does not get enough support andfurther skills enhancement. They canthen develop what is called secondaryor vicarious traumatisation. In additionto being harmful to the staff, this wouldundermine the Project because staff,feeling overwhelmed, could then stopasking clients about GBV or else ask inways that communicated to the clientsthat they did not really want to knowthe true answers to these questions.

To counteract this, it is necessary tohave an on-going support andsupervision component to the Projectthat gives staff the opportunity todiscuss difficult feelings they have, getfeedback on perplexing and upsettingcases, get support for doing this workand gain new skills. Staff support andsupervision is as important as training.

It is also a way to fine-tune the Projectby finding out what is working and whatis not going well, what needs to berethought or added, and whatadditional skills the staff needs in orderto work with victims of GBV. Having asupervision meeting once a month ledby a trained facilitator would allow staffto gain skills and feel supported in theGBV work they are doing. The moreskills and tools the staff have, the morecompetent they feel and the better theycan do this work.

9.1.17 Network With and Involve theCommunity

One way to raise awareness about atopic is to introduce ideas and ways ofthinking about the topic that are novel.This is true with GBV. Firstly, somepeople may not even be aware that

GBV is a topic that no longer is aprivate matter and that it in realityeffects the whole community.Community workers can organisemeetings that address this topic byfocusing on original themes that wouldinterest various people and communitygroups. Such themes include: thecosts of GBV to the city and country,GBV laws in this particular country, theeffects of GBV on children, and how torecognise symptoms of domesticviolence and other forms of GBV in avictim. These are all topics to use tobegin a discussion of GBV.

Informing citizens at these meetingsabout your facility's GBV Project andthe services you offer women is a wayto publicise these activities. Bringingmaterial about GBV to these meetingsallows participants to take these, readthem and possibly pass along to otherswho may be victims of GBV. Theparticipants can then act as informalreferrers to the GBV Project.

Another way to effect change is toeducate specific groups of people.Initiating groups for men in thecommunity where they can talk aboutmale socialisation and gender rolesand the effect this has on theirrelationships with women is oneexample of this. These groups can beshort-term and allow men, possibly forthe first time, to look at their values andbehaviour and work on changingabusive behaviour. When led bytrained leaders these can be powerfulgroups. These types of groups havebeen successfully conducted in anumber of countries and there iswritten material available that can beused as a guide to facilitate a men's

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group. This is an excellent way toinvolve men in the issue of GBV (Corsi,1999).

9.1.18 Expand Staffing and Services

If, as in Project C, there is to be on-sitetreatment, staff at the facility who havean interest and propensity for this workcan be trained in the assessment andtreatment of GBV. Or else, new staffcan be hired to do the psychologicalcounselling. These people would betrained social workers or psychologistswith an expertise both in the treatmentof GBV and group work, who couldlead support groups for victims of GBV.There could then be groups for rapevictims, battered women andadolescent and adult victims ofchildhood sexual abuse. These groupsare both helpful to victims of GBV andan economical way to offer effectiveservices.

Another option is to train formerlybattered women or survivors of rape sothat they can run support groups forvictims of GBV. As part of the job, theycould first meet with victims of GBVand assess clients by administering anin-depth assessment of the GBV andits effects. (See Appendix 9.) Duringthis meeting she would also get abetter sense of the victim's situationand evaluate what type of services sheneeded - legal, psychological, housing,support or psychosocial, on-site or off-site.

An additional service that Project C canoffer is on-site legal assistance tovictims of GBV. The lawyer could meetwith victims of GBV and give theminformation about their legal rights,answer specific legal questions andassist them in finding ways to protectthemselves from the perpetrator.

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Appendices

Appendix 1. Facility Assessment Form...................................................................44

Appendix 2. Sample Project Work Plan...................................................................45

Appendix 3. Sample Monitoring and Evaluation Plan ...........................................46

Appendix 4. Creating a Referral Network................................................................47

Appendix 5. Asking about Gender-Based Violence...............................................48

Appendix 6. Sample Documentation Form..............................................................52

Appendix 7. Danger Assessment .............................................................................53

Appendix 8. Safety Planning.....................................................................................54

Appendix 9. In-depth GBV Assessment Form (for Project C) ..............................55

Appendix 10. Body Map...............................................................................................57

Appendix 11. Monthly Data Summary Table .............................................................58

Appendix 12. Sample Exit Interview...........................................................................59

Appendix 13. Evaluation of this Programme Guide.................................................60

Appendix 14. Sources of Information on Gender-Based Violence ........................61

Chapter

10

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Appendix 1. Facility Assessment Form

A. What Is Currently Being Done at Your Facility about GBV?

1. Has any of the staff had any general sensitisation on the topic of GBV?

2. If so, what type of training was it and who participated in it?

3. Is there any written material in the waiting room on GBV?

4. Has the staff been trained to identify, assess and assist victims of GBV?

5. Are clients presently asked about GBV at your facility?

6. If yes, is there a place in the client registration form or in the charts to document this?And is there a place to write notes regarding GBV?

7. Do you have a list of agencies at your facility to refer victims of GBV to?

B. Levels of Staff Interest and Concern

1. What is the interest level of the different staff in doing such a Project?

(Rate on a scale of 1-5, 1 = lowest; 5 = highest level of interest)

Staff Category Average Levels ofInterest (1-5)

Comments

a. Health workersb. Doctorsc. Nurses/Midwivesd. Administratorse. MISf. Educationg. Social Workersh. Support Staff

2. What does the staff see as the benefits to a GBV Project?

3. What does the staff see as the drawbacks of a GBV Project? (Use this information toaddress the concerns of staff about starting a GBV Project. Find a forum, such as a staffmeeting, to discuss this.)

C. Potential Problem Areas

It is normal to experience difficulties. Examples of areas of concern are:

• How to introduce this Project to the staff

• How to evaluate this Project

• How to train all the staff

• How to take a step-by-step approach and not jump over steps

• How to deal with staff’s time concerns

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Appendix 2. Sample Project Work Plan

Date of sample work plan - January 1, 2002

Step Activity Person (s) Responsible Deadline

Assess staffcapability

(Use form inAppendix 1.)

Interview individual staff members Staff supervisor January 19

Hold staff meeting to discussconcerns, etc.

Clinic Director January 26

Plan how to deal with issuesidentified

Senior staff February 9

Assess financialresources

Hold meeting to discuss resources Clinic Director, Accountant January 19

Assess referralservices

Identify possible resources viatelephone, meetings, internet, etc.

Provisional Project Coordinator January 26

Etc.

Etc.

Etc.

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Appendix 3. Sample Monitoring and Evaluation Plan

Activity Indicator Data Source PersonResponsible

How Often

Process-Sessionsheld

Project records Project Coordinator On-going

Staff sensitisation Pre and post Project Coordinator With eachsensitisation

Staff sensitisation

Output - improvedawareness,knowledge andattitudes

Process - Number orpercentage of clientsscreened

Client charts Clinical staff DailyScreen clients forGBV

Output - Number orpercentage ofwomen screenedwho say "yes"

Monthly datasummaries (seeAppendix 11)

Project Coordinator Monthly

Etc.

Etc.

Etc.

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Appendix 4. Creating a Referral Network

Name of institution:

Director of Institution:

Type of institution:

Hours and Days Open:

Phone Numbers:

Fax Numbers:

Address:

E-mail Address:

What type of population do you serve? Do you specifically see victims of GBV?

Yes/No

What is the profile of the victim you serve? Does your group have any criteria that a potential client would have tomeet?

Do you provide direct care or do you make referrals? If you do provide direct care, what type is it? (Legal,medical, social, psychological, educational, etc.)

If you make referrals, where do you refer? Do you charge a fee? Yes/No

If yes, do you have a fixed fee or can you makeaccommodations?

What is the profile of your staff who see victims of violence? Are there other activities that your institution offers?

Are you aware of any other institutions that offer care tovictims of GBV? If so, can we have this information so wecan contact them?

Would you be interested in our two institutionsmaking cross-referrals?

Yes/No

Would you be interested in being a part of a network of groups that work in the area of GBV? Yes/No

Instructions

• Get names of potential referral resources from non-governmental organisations (NGOs), hospitals,community leaders, and people at the district level.

• If possible, request a face-to-face interview with the possible referral resource. Above is a sample set ofquestions that can be used to evaluate each group that is interviewed.

• Offer to keep in contact and work together on creating a network, if they are interested.

• Write up the resource list using the information that has been gathered. Divide the referral book up intodifferent types of referral topics, putting all relevant referrals together under each area, i.e., legal, social,housing, medical, and psychological. Put it into a book with one referral per page, including relevantinformation about this institution that could be useful when deciding what institution could best help aparticular client.

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Appendix 5. Asking about Gender-Based Violence

A. Principles Behind Asking about GBV

It is important to ask questions about GBV in such a way that clientsunderstand exactly what you are asking them. It is important not to usetechnical or negative terms that will confuse her or cause the client to feelblamed. It is best to use questions that describe behaviours and ask a clientwhether she has experienced these (see examples below). It is important forthe staff to feel comfortable asking these questions. If they do not, the personasking will communicate their discomfort to the client and the client will thenanswer “no” to the questions, when they may in fact be victims of GBV.

It is crucial that every staff member in a Project who asks clients about GBVask the same set of questions. This is important in order to collect data that willthen show how many clients have experienced what types of GBV. The GBVcoordinator or other personnel must decide which specific questions clients willbe asked about GBV. Deciding which questions will be asked must be decidedupon before the training of the clinical staff because they will be the people whowill be asking clients these questions.

Before actually asking a client the questions about GBV, it would be importantto first explain to the client why you are going to be asking her these questionsand normalize the topic by using one of the following suggested openings:

"I ask all clients these questions."

"I know that there are many women who are victims of GBV and we believe at our facility that it isimportant for us to talk with clients about this."

"I know that there are things that have been considered private in society and that has included violenceagainst women. At our place we don't believe that this is a private matter. We think it is important to talkabout these things."

"Sometimes people are told that it's okay if they are hit or being abused by someone they care about.People say that this is an expression of love. But I know that this is something that should not happen.No one deserves to be hit or sexually abused in any way. I want to know if this has happened to you."

B. Asking questions about GBV

Questions need to be asked that can identify three types of GBV -- childhoodsexual abuse, rape and domestic violence. There are sample questions ineach of the categories listed below. Whatever questions are chosen, theyshould be written out on a form or kept close by in the room where women areassessed for GBV. This way, health workers will be able to use them asprompts and each health worker will ask the same set of questions.

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Choose your Project Questions (Sample questions to ask clients about GBV)


• Sometimes women are touched as children in ways that do not feel good? Did that happen to you?

• Did anyone ever try to touch you in a way that made you feel uncomfortable?

• As a child, did anyone touch you in a sexual way?

Rape

• Have you ever felt forced or pressured to have sex when you did not want to?

• Has someone you know or a stranger ever make you do something sexual that you did not want to do?

• Do you feel that you have control over your sexual relationships and that you will be listened to if you say"no" to having sex?

Domestic Violence

It is important to ask clients questions about different forms of domestic violence. (Rape as one aspect ofdomestic violence is included in the sample questions on rape.)

• Has a partner ever hit, kicked or slapped you or threatened to do so?

• Are you frightened of your partner?

• Has a partner ever criticised you, insulted you, yelled at you? Has your partner ever destroyed your thingsor objects in the household?

• Has a partner ever threatened your life, isolated you from family or friends, refused to give you money ornot allowed you to leave the house?

Or more generalised questions can be asked:

• As an adult have you ever been injured or hurt by any kind of abuse or violence, for example, hit by apartner or forced to have sex?

• Is there anyone you are afraid of now?

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C. Responding to the Client's Answers

If the client answers "yes" to any of the questions about GBV, you need to givethe client support and validation. You can respond by saying:

“I'm sorry that this happened to you. I need to ask you more questions so that we can get you somehelp.”

“No one deserves to be abused. You do not deserve to be abused. I know it is not easy for the personwho is going through this.”

“I'm glad that you were able to tell me. I think we can help you here. I need to ask you a few morequestions about the GBV and that will give me more information so that together we can figure out thebest options for you.”

Get more information from the client if the client answers “yes”

You then need to ask her for more information such as who was (or is) theperpetrator, how long the abuse went on for, and if she is in danger now. (SeeAppendix 6 for the list of questions.) You would also want to get a sense ofwhat types of referrals this client needs at this time. Give the client some ideaof what referral options are available and discuss these options with her.

If the client answers “no” to the questions about GBV

Clients may answer "no" because they may never have experienced GBV.Even though she has said “no”, asking again when a woman returns to thefacility is important because circumstances change. For instance, a womanmay get into a new relationship and it may be violent, or a woman after shebecomes pregnant may start experiencing physical violence from her partner.

For a number of reasons, clients who are victims of GBV may say "no" to thequestions about GBV the first time they are asked about this. Clients who havenever talked about their experiences of GBV may not feel comfortabledisclosing this immediately. They will need time to first feel safe or trust staffbefore answering this honestly. They also may feel frightened of disclosing thisbecause of threats the perpetrator has made. This is why it is important to askclients these questions each time they come. Some women have said thatbeing asked repeatedly about GBV by their providers was what finallypersuaded them to disclose the abuse. These women said "yes" because theyfelt that the provider had persevered by repeatedly asking, thereby letting themknow they care and want to know.

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Although it is important to ask clients each time they come to the facility if theyare victims of GBV, it would not be helpful to try to force a client to discloseGBV before she was ready to do so. Actually, it may have a negative effectand consequently she might feel threatened by this and not return to the clinic.So if a client says "no" in answer to your questions about GBV but you suspectshe is being abused, remember that she can only tell you when she is ready todo so. You can help her by respecting that and recognising that it takes timebefore someone can disclose a secret that she has kept for a long time.

If the client answers "no" but the provider thinks that the client may havebeen a victim of GBV.

The provider, if s/he suspects that the client is a victim of GBV, needs todocument this in the documentation form. As stated above, some clients maybe unable to initially disclose this information. That is why it is important tocheck off the "maybe" box in the documentation form (see Appendix 6). Thisway, staff at the facility could be alerted to this possibility. It is also critical toask these clients questions about GBV when they return to the clinic.

D. Overview of screening, assessment and documentation

Project A

If a womanapproaches a staffperson about theeducational materialabout GBV:

• Take her into a privateroom

• Respond to what she saysin a caring, supportivemanner

• Ask her questions abouther experience of GBV, ifappropriate

• Make an appropriatereferral

Project B

Asking a client aboutGBV and the clientsays “yes”:

• Respond in a caring,supportive manner

• Get more information aboutwhat happened

• Find out if she is in dangernow

• If she is in danger go overthe danger assessmentform and make a safetyplan with her

• Make a referral

• Document all of this in herchart

Project C

Asking a client aboutGBV and the client says“yes”:

• Respond in a caring,supportive manner

• Get more information aboutwhat happened

• Refer her for an in-depthassessment, which includes adanger assessment and areferral, on-site or off-site

• Make a safety plan, if needed

• Document all of this in herchart

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Appendix 6. Sample Documentation Form

Have a rubber stamp made to put in each client’s chart. It can look like the one below.

Type of GBV No Yes Maybe


Rape/Sexual Assault

Domestic Violence

When the client answers the questions about GBV, the answers need to be put in her chart. If astamp is used (as above) the health worker can check off the appropriate boxes in the stamp.(Domestic violence that is sexual goes in the "rape/sexual assault" box.) If the client answers"no" but the health worker suspects that the client has experienced or is experiencing GBV or ifthe client herself is unsure, the health worker needs to check-off the "maybe" column next to thespecific type of GBV. (See Appendix 5 for more information about a client saying "no" and aprovider checking off the "maybe" box.)

For Project B

(Questions to ask if the client answers "yes" to any of the GBV questions)

When did this occur?

What is the perpetrator's relationship to the client?

What is the length of time the GBV went on?

How has the GBV affected the client?

Does the client report any re-victimization experiences?

Does the client feel in danger now?

If so, fill out the danger assessment form (see Appendix 7) and make a safety plan, if appropriate (seeAppendix 8).

Referral given? Where? Accepted by client?

The above form should be attached to the client's chart along with any other information aboutGBV.

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Appendix 7. Danger Assessment

If a client discloses that she is currently in a violent relationship or she is thinkingof leaving a violent relationship she needs to be assessed for danger. Askingthese questions and finding out the answers will educate the client about herlevel of danger. Knowing the level of danger will help the provider and the clientthink through what her options are. To further help her, the provider may need towork on safety planning with the client. (See Appendix 8 for the safety planningform.)

1. Has the violence increased in the past year?

2. Does the perpetrator use drugs and alcohol?

3. Has the perpetrator made threats to kill you?

4. Are there weapons in the home?

5. Are you afraid to go home?

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Appendix 8. Safety Planning

(Adapted from the New York State Office for the Prevention of Domestic Violence)

A. Increasing Safety in the Relationship

If I need to leave my home, I can go to ___________________ (list 3 places you can go).

I can tell _________ (list 2 people) about the violence and ask them to call the police if they hear loudnoises coming from my home.

I can leave extra money, clothing, car keys and copies of documents with_________________ (list oneperson)

If I have to leave, I will take ____________________with me.

To ensure safety and independence, I can keep change for telephone calls with me at alltimes, open my own bank account, rehearse an escape route from my home and review thissafety plan.

B. For Increased Safety When the Relationship is Over

I can change the locks, put better lighting outside my home, and install a better door.

I can inform _____________________ (list at least 2 people) that my partner no longer lives with me andask them to contact ____________________ (me, the police, others) if he is seen near my home.

I will tell the people who take care of my children the names of the people who have permission to pick upmy children. Those people who have permission are_______ (list all the people this applies to).

I can tell ________________________ (list people) at work about my situation and ask them to screen mycalls.

I can obtain a protective order from_____________________ and keep it with me at all times. I can alsoleave a copy of it with _________________. (If applicable, list one person.)

If I feel down and ready to return to a potentially abusive situation I can call ________________________(list at least one person) for support or attend groups to get support and strengthen my relationships withother people.

C. Important Telephone Numbers: D. Items to Be Sure to Take With Me (make a list here)

_______________________ __________________________

________________________ __________________________

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Appendix 9. In-depth GBV Assessment Form (for Project C)

1. Client Name 2. Client ID# 3. Provider Name 4. Date

5. Type of GBV (Tick off all that apply) a. Childhood Sexual Abuse b. Rape c. Domestic Abuse

6. History of GBV 7. Present Day Effects (Place a tick mark in the appropriate column)

Symptoms Yes No Comments of Staff Membera. When this occurred

Depression

Drug/alcohol abuseb. Perpetrator's relationship to client

Anxiety/panic attacks

Sexual/intimacy problemsc. Physical, sexual, verbal, emotional, psychological abuse

(Check all that apply) Eating/sleeping too much or too little

Self-harmd. Length of time abuse went on (note if still going on)

Shame/self-blame

Numbness, intrusive memoriese. Told anyone about this before? Got help?

Suicidal thoughts/behaviours

Post-Traumatic Stress Disorderf. Any contact now with perpetrator? Yes/No

If “yes”, go to question 11. Physical injuries and problems

g. Was a safety plan discussed with the client? Yes/No Other symptoms (specify)

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11. Danger Assessment8. Effects on client’s children

a. Has the violence increased in the past year?

b. Does the perpetrator use drugs and alcohol?9. Re-victimisation experience(s)

c. Has the perpetrator made threats to kill you?

d. Are there weapons in the home?10. Other Comments

e. Are you afraid to go home?

12. Referral

Type of Service Name of Referral On-site Off-site

Support group

Counselling

Legal

Housing

Social services

Hotline number

Other (specify)

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Appendix 10. Body Map

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Appendix 11. Monthly Data Summary Table

Total Number of Clients, Clients Asked about GBV and Clients Reporting GBV, by Clinic andType of Violence

(1)

ClinicName

(2)

TotalClients

(3)

ChildhoodSexualAbuse

(4)

Rape *

(5)

DomesticViolence

(6 = 3+4+5)

Total AbuseCases

(7 = 6/2)

Abuse Cases%

a.

b.

c.

d.

e.

Total

*The category "Rape" includes rapes committed as part of domestic violence.

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Appendix 12. Sample Exit Interview

In order to get an assessment of quality of care from clients, you can do a study using exitinterviews of randomly selected clients. For one week, ask every 5th or 10th client about herexperience of the GBV Project. Below are some possible questions that these clients could beasked. It would be important to ask them these questions in a private place since they touch on asensitive issue.

Interview Questions About Responses to the GBV Screening

1. Did you look at the GBV material in the clinic?

2. What did you think of them? Were they informative? Easy to read? Helpful? Do you feel yougot new information about this topic by reading the material?

3. If you did not read the material, why not? Would there be anything that we could do thatwould make the material more desirable to read?

4. If you had a friend who told you she was being abused would you pass along this material toher? If yes, why? If no, why?

5. Do you have any other comments about the posters, cards, booklets or brochures we haveon GBV?

6. Do you believe it is a good idea to put this type of material out in a health clinic for women?

Interview Questions About Being Asked about Responses to the GBV Screening

1. As part of the client intake, were you asked about GBV?

2. Did you think that when the staff person asked you these questions she really wanted toknow your answers?

3. Do you think it is important for women to be asked such questions when they come to ahealth care facility?

4. If you were to answer "yes" to the GBV do you think that you could get the help you needhere? If yes, why? If no, why?

5. If someone you knew was a victim of GBV would you send her here to get help? If yes, why?If no, why?

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Appendix 13. Evaluation of this Programme Guide

1. Overall, how would you rate this programme guide? Circle yourresponse.

Excellent Good Fair Poor

2. What was most helpful about this programme guide?

3. What has least helpful about this programme guide?

4. Additional comments about the programme guide

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Appendix 14. Sources of Information on Gender-Based Violence

ANNOTATED BIBLIOGRAPHY

I. GENDER-BASED VIOLENCE

American Medical Association. (1995). Diagnostic and Treatment Guidelines onMental Health Effects of Family Violence. [Brochure]. A portable-sized booklet thatdiscusses the role of the physician in working with victims of gender violence.Focuses on assessment, treatment and referrals of these patients. Summarises thepsychological effects of trauma on patients and describes how to take an abusehistory and emphasises the importance of this. To order, visit AMA's Web site athttp://www.ama-assn.org/violence

Heise, Lori, Ellsberg, Mary, & Gottemoeller, Megan. Ending Violence AgainstWomen. Population Reports. Series L, No. 11. Baltimore, Johns Hopkins UniversitySchool of Public Health, Population Information Program. (1999). This documentfocuses on the two most common types of violence against women: abuse ofwomen within intimate relationships and coerced sex which can take placethroughout a woman's life. It discusses the causes of gender-based violence, theimpact of the violence on the individual, family and community and also what healthcare providers can do to assist victims of GBV. Has statistics and prevalence ratesof GBV from many countries.

Heise, Lori, Moore, Kirsten & Toubia, Nahid. (1995). Sexual Coercion andReproductive Health. New York: The Population Council. A report from a seminarsponsored by the Population Council on gender violence that brought togetherdifferent groups and disciplines to develop a health research and action agenda onthe effects of sexual violence on reproductive health.

Heise, Lori with Pitanguy, Jacqueline & Germain, Adrienne. (1994). ViolenceAgainst Women: The Hidden Health Burden. Washington, D.C.: The World Bank. Acomprehensive documentation of the problem of gender violence. Looks at thehealth effects, its effects on development and steps that can be taken to eliminategender violence. Includes DALYs, the disability-adjusted years lost to women that isattributable to domestic violence and rape.

Heise, Lori .(1994). Gender-Based Violence and Women's Reproductive Health.International Journal of Gynecology and Obstetrics,46: 221-229. Speaks to themany ways that gender violence affects reproductive health including unwantedpregnancy, HIV, STDs, teenage pregnancy, somatic problems and outlines waysthat health care providers can intervene by asking about gender violence.

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II. DOMESTIC VIOLENCE

American Medical Association. (1992). Diagnostic and Treatment Guidelines onDomestic Violence. Chicago. [Brochure]. A portable-sized programme guide forhealth care providers which includes basic information on the assessment,diagnosis, interventions, documentation and barriers to identification of domesticviolence. To order, visit AMA's Web site at http://www.ama-assn.org/violence.

Olavarrieta, Claudia Diaz & Sotelo, Julio. (1996). Letter from Mexico City: DomesticViolence in Mexico. Journal of the American Medical Association, 275, (24): 1937-1941. A short article describing the history of domestic violence in Mexico, thejudicial obstacles to reporting it and the availability of services for victims.Acknowledges the cultural acceptance of this public health problem as a one barrierto changing how Mexico responds to the problem of domestic violence.

Rodriguez, Michael, Guiroga, Seline Szkupinski & Bauer, Heide. (1996). Breakingthe Silence: Battered Women's Perspectives on Medical Care. Archives of FamilyMedicine, 5, 153-158. Using focus groups the authors listened to battered womenspeak about what from the victim's perspective inhibited disclosure of domesticviolence. The women also spoke about the factors that enhance disclosure, whichincluded feeling that providers were aware, compassionate and respectful of theirpatients.

United Nations. (1993). Strategies for Confronting Domestic Violence: A ResourceProgram Guide. Center for Social Development and Humanitarian Affairs: Vienna.Written by a group of experts based on the report of the Secretary-General of theUnited Nations on domestic violence. Presents a range of options and strategiesthat are being used in different parts of the world to deal with the problem ofdomestic violence. Includes chapters on improving the criminal justice system,working with perpetrators and training practitioners.

III. RAPE

American Medical Association. (1995). Strategies for the Treatment and Preventionof Sexual Assault.{Brochure} Describes the needs of victims of sexual assault in anemergency setting and in a primary care setting. Asks physicians to be aware ofand respond to both the physical effects of the trauma and to the psychologicalaftermath. A special focus on adolescents as a vulnerable population. To order,visit AMA's Web site at http://www.ama-assn.org/violence

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IV. ADULT MANIFESTATION OF CHILDHOOD SEXUAL ABUSE

Stewart, Lindsey, Sebastiani, Angela, Delgado, Gisella & German Lopez. (1996).Consequences of Sexual Abuse of Adolescents. Reproductive Health Matters. 7:129-134. This article uses interviews with girls in Peru and Columbia to show theextent and consequences of sexual abuse among female adolescents. Theydescribe both the behavioural and psychological effects. They connect childhoodsexual abuse to sexual risk-taking in adolescence, including poor or non-use ofcontraceptives. The authors believe that health care providers must be trained todeal with this problem and that facility policies and procedures must also be inplace to help the patient and support the provider.

Contraceptive Technology Update. (1994). This is a special focus series of articleson the abuse of women. Using studies that have been previously done, theyconnect childhood sexual abuse to contraceptive non-compliance. This is importantbecause often health care providers see the non-compliance but do not understandwhy patients are not using contraceptives. It also alerts providers to look for thepossibility of revictimization in adolescence and adulthood for these women. Theseries includes a piece written from the point of view of an abused woman on whata provider can do to help an adolescent or adult woman who was sexually abusedas a child. 15, (10): 113-139.

V. ASSESSMENT AND TREATMENT ISSUES

Herman, Judith. (1992). Trauma and Recovery. New York: Basic Books. Athoughtful book that connects domestic violence and childhood sexual abuse to theeffects of combat. Speaks to the effects of trauma and the different stages andneeds that victims have to go through to heal.

Stevens, Lynne. (1997). Sexual Abuse Victims: Assessing and Diagnosing theTrauma in Adolescent and Adult Women. Advance Magazine for PhysiciansAssistants. 5,(5),:47-49. Describes how adolescent and adult victims of childhoodsexual abuse present in health care providers' offices. Defines the problem, listspossible symptoms victims have, describes why victims don't bring this up withproviders and how to assess and diagnose the long-term effects of sexual abuse.(E-mail: [email protected]).

Stevens, Lynne. (1997). Breaking the Silence: Talking About Sexual Abuse WithFemale Patients. Advance Magazine for Physician Assistants, 5 (8). Asks healthcare providers to ask patients about a sexual abuse history. Describes the benefitsto asking, who to ask, how to bring this topic up with patients, how to respond ifpatients say they were abused, how to give support to patients and how to make areferral. (E-mail: [email protected]).

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Web sites to Use to Get Information and/or Material on GBV

1. Victim Services – in English and in Spanish: www.vicitmservices.org

2. Women Watch: www.un.org. Look in particular for (a) Final Report ofWomen Watch online working groups on all critical areas of concern ofBeijing +5, including health, VAW, women and armed conflict.E/CN.6/2000/PC/CRP1. (b) All Beijing +5 documentation, in English,French, Spanish very often, especially Expert Group Meeting reports onthe three areas mentioned above. (3) Links especially to NGO pages.

3. United Nations Commission on Human Rights (UNHCHR) –www.unhchr.ch for all reports of the Special Rapporteur on VAW,available in three languages above. Note specially, her reports on (a)Policies and practices that impact women’s Reproductive Rights andcontribute to, cause or constitute VAW. E/CN.4/1999/68/ADD.4 21Jan.1999 (b) on Trafficking in women, women’s migration and VAWHealth aspects addressed. E/CN.4/2000/68, 29 FEB 2000 (c) VAW infamily, domestic violence E/CN.4/1999/68 (d) VAW in armed conflict,custodial violence, refugee and internally displaced women –E/CN.4/1998/54.

4. United Nations Development Fund for Women (UNIFEM) home pagewww.undp.org/unifem for its pages on Human Rights and especially onUN General Assembly Trust Fund on eliminating VAW which givesinformation on activities and updates.

5. World Health Organization (WHO) home page www.who.int/ especially for(a) Prevalence and data on VAW at country level compiled from manysources (b) VAW bibliography (c) info on their on-going Multi-CountryStudy (d) forthcoming World Report on Violence, including gender-basedviolence.

6. UN Resources on Gender: www.undp.org/. Look especially at the GenderGood Practices Database http://www.undp.org/gender/practices/ whichcontains examples in area of VAW from many UN agencies including onhealth aspects (e.g., PAHO).

7. Population Council: www.popcouncil.org – especially for the report“Sexual Coercion and RH: A Focus on Research” (Executive Summary).

8. Men’s Resource Center of Western Massachusetts www.mrc-wma.com.In addition to information on its own programmes, provides good links toother Web sites on “men” that deal with GBV among other issues.

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9. IPAS: www.ipas.org – information on provision of reproductive healthservices for rape victims including safe abortion and after-care, amongtheir other programmes.

10. Family Violence Prevention Fund: www.fvpf.org includes their Newsletter,screening information, and materials such as posters, stickers and cardson domestic violence for sale.

11. International Planned Parenthood Federation/Western HemisphereRegion: www.ippfwhr.org – has a newsletter, Basta! about its GBVprojects in Latin America and the Caribbean.

12. White Ribbon Campaign: www.whiteribbon.ca/eindex.html – a group of"men working to end men's violence against women." Offers a newsletter,educational material for adolescent and adult men about violence againstwomen, and counselling resources for abusers.

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A Practical Approach to Gender-Based Violence:A Programme guide for Health Care Providers and Managers

References

Corsi, J. (1999). Treatment for Men Who Batter Women in Latin America. AmericanPsychologist 54, 1, 62-65.

deLahunta, E., & Tulsky, A. (1996). Personal Exposure of Faculty and Medical Students toFamily Violence. Journal of the American Medical Association, 275, 24:1903-1906.

Eby, K., Campbell, J., Sullivan, C., & Davidson, W. (1995). Health Effects of Experiences ofSexual Violence for Women with Abusive Partners. Health Care of Women International, 16,563-567.

Family Violence Prevention Fund. (2000). Preventing Domestic Violence: Clinical Guidelineson Routine Screening. Web site: www.fvpf.org/health/screpol/html

Friedman, L., Samet, J., Roberts, M., Hudlin, M., & Hans, P. (1992). Inquiry aboutVictimization Experiences: A Survey of Patient Preferences and Physician Practices.Archives of Internal Medicine, 152, 1186-1190.

Heise, L., Ellsberg, M., & Gottemoeller, M. (1999). Ending Violence Against Women.Population Reports. Series L, No. 11. Baltimore, MD: Johns Hopkins University School ofPublic Health, Population Information Program.

Heise, L., Moore, K., & Toubia, N. (1995). Sexual Coercion and Reproductive Health: AFocus on Research. New York, NY: The Population Council.

Kilpatrick D., & Best. C.L. (1990). Sexual Assault Victims: Data from a Random NationalProbability Sample. Presented at the 36th Annual Meeting of the Southeastern PsychologicalAssociation, Atlanta, Georgia.

Koss, M. (1993) The Impact of Crime Victimization on Women's Medical Use. Journal ofWomen's Health 2,1:67-72.

Mazza, D., Dennerstein, L., & Ryan, V. (1996). Physical, Sexual and Emotional ViolenceAgainst Women: A General Practice-Based Prevalence Study. Medical Journal of Australia,164, 14-17.

Russell, D. (1986). The Secret Trauma: Incest in the Lives of Girls and Women. New York,NY: Basic Books, Inc.

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Sexual Assault Report. March/April, 2000. Vol. 3. No. 4. Pg. 58. Civic Research Institute, Inc.

Shamin, I. (1985). Kidnapped, Raped and Killed: Recent Trends in Bangladesh. Paperpresented at the International Conference on Families in the Face of Urbanization, NewDelhi, India.

United Nations General Assembly. (January 1992.) General recommendation 19 (eleventhsession) — Violence Against Women. Report of the Committee on the Elimination ofDiscrimination against Women. A/47/38.

United Nations General Assembly. Declaration on the Elimination of Violence AgainstWomen. Proceedings of the 85th Plenary Meeting, Geneva, Dec. 20, 1993.

United Nations General Assembly. (May 1999.) General recommendation 24 (twentiethsession). Article 12 of the Convention on the Elimination of All Forms of Discriminationagainst Women — Women and Health. Report of the Committee on the Elimination ofDiscrimination against Women. A/54/38 (Part I).

United Nations General Assembly. (2000.) Women 2000: Gender Equality, Developmentand Peace for the Twenty-First Century. Unedited final outcome document as adopted bythe plenary of the special session.

United Nations Population Fund. (1994.) Report of the International Conference onPopulation and Development, Cairo, 5-13 September 1994. New York<www.undp.org/popin/icpd/conference/offeng/poa.html>

United Nations Population Fund. (1998). Programme Advisory Note. Reproductive HealthEffects of Gender-Based Violence: Policy and Programme Implications . New York

United Nations Population Fund. (2000). The State of the World Population 2000. LivesTogether, Worlds Apart: Men and Women in a Time of Change. New York

World Health Organization. (1997). Violence and Injury Prevention: Violence against women:A Priority Health Issue. WHO Information Kit on Violence and Health. Geneva:<www.who.int/violence_injury_prevention/vaw/infopack.htm>

Wyatt, G., Gutherie, D., & Notgrass, C. (1992). The Differential Effects of Women's ChildSexual Abuse and Subsequent Sexual Revictimization. Journal of Consulting and ClinicalPsychology, 60, 2:67-73.

Zierler, S., Feingold, L., Laufer, D., Velentgas, P., Kantrowitz-Gordon, I., & Mayer, K. (1991).Adult Survivors of Childhood Sexual Abuse and Subsequent Risk of HIV Infection. AmericanJournal of Public Health, 81(5):572-75.

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This card is a prototype. Adapt it to your context

SAVE

S=SCREEN all clients for Gender-Based Violence (GBV).GBV is a public health problem. All women are vulnerable to GBV. Health care providersare the group that women want to talk to about GBV. Many women will not volunteer thisinformation but will disclose GBV if their provider asks them.

A=ASK direct questions about GBV in a non-judgmental manner in a private setting. Donot use formal, technical or medical language. Normalize why you are asking about GBVbefore asking questions about GBV.

EXAMPLES OF WAYS TO INTRODUCE THE TOPIC:o "I know that we just met but I have to ask you these personal questions. We do thisbecause there are many women who are victims of GBV and we believe it is important totalk about this here. What you tell me will be kept confidential"o " I know that there are things that are considered private in society and that has includedviolence against women. I don't believe that this is just between two people. No onedeserves to be abused. I want to ask you some questions about what is going on in yourlife…"

Find ways to ask that feel comfortable for both you and the client.

EXAMPLES OF QUESTIONS TO ASK ABOUT GBV:o Has a partner ever hit, kicked or slapped you or threatened to do so?o Have you ever felt forced or pressured to have sex when you did not want to?

HERE'S WHERE THE QUESTIONS YOUR FACILITY WILL USE WILL GO:

V=VALIDATE the client's response.If a client answers "yes" to any of your questions offer her support. Do not minimize theclient's response even if she does. Let her know you believe her and that no one deservesto be abused. Let her know help is available. Be sure to document the type of abuse andnote the physical and psychological findings related to the GBV in the client's chart. If aclient answers "no" but you suspect that she is a victim of GBV make a note about this inher chart and be sure to follow-up by asking again in the future.

E=EVALUATE, educate and refer.Ask the client how you can help her. Offer her empathy, educational information andreferrals. Let her know that you will not judge her if she does not follow-up with the referralnow. If she is hesitant to take a referral now, let her know she can change her mind andreceive one at some later time. Follow-up and mention the disclosure of GBV during hernext visit.

Adapted from the NYS Coalition Against Sexual Assault SAVE card

A Practical Approach to - WHO€¦ · Rape victims are nine times more likely than non-victims to...

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