Strengthening Health System Responses to Gender-based Violence in Eastern Europe and Central Asia

A resource package

3.4. Risk assessment and safety planning

The safety of patients who experienced GBV must be at the centre of any health sector intervention to GBV. In case of intimate partner violence, isolated occurrences of violence are rare; the danger of repeated offences is very high. In times of separation and divorce, the risk of violence even increases: The majority of murders, attempted murders and acts of serious violence are committed when a survivors attempt to leave violent partners. Ironically speaking, it may thus be safer for women to stay in a violent relationship than to end it (WAVE 2006).

Health care professionals have an important role to play in supporting a survivor through jointly assessing potential risks of further violence, supporting her in her safety planning, as well as offering referrals to a shelter (for more information on referrals, see chapter 4). As a first step, health professionals need to understand risk factors for repeating or escalating violence.

3.4.1 Understanding risk factors for repeating or escalating violence

The following list of risk factors has been identified in international studies as risk factors for a high degree of dangerousness in instances of intimate partner violence (Gondolf 2001, Robinson 2004, Humphreys at al 2005, all cited in WAVE 2006). As a general principle, the more factors that apply in a specific case, the higher the risk is that acts of violence will be repeated or that the violence may increase or even escalate (WAVE 2006).

Risk factors for a high degree of dangerousness in case of intimate partner violence (adapted from WAVE 2006):

  • Previous acts of violence against the woman, the children or other family members, as well as former partners:Look at the history of abuse, forms and patterns of violence used as well as former convictions or reports to police. Perpetrators who have committed frequent, severe acts of violence (such as using a weapon or strangling the survivor) are particularly dangerous.
  • Previous acts of violence outside the family, e.g. against the staff of service providers or authorities, indicate a general tendency to use violence also within the home.
  • Separation and divorce are times of high risk.
  • Acts of violence committed by other family membersof the perpetrator may be used to control the survivor and result in making it impossible for her to flee.
  • Possession and/or use of weapons: Legal or illegalpossession of weapons increases the risk of armed violence, especially when the perpetrator has used, or threatened to use weapons in the context of earlier episodes of violence.
  • Abuse of alcohol or drugsdoes not in itself cause violence, but may lower the threshold and thus contribute to an escalation of violence.
  • Threatsshould always be taken serious. It is wrong to assume that persons who “only” use threats are not dangerous – in fact, severe violence is often preceded by threats. In particular, threats of murder must be taken serious: In many cases of women being killed by intimate partners, they had been repeatedly threatened with murder before being killed.
  • Extreme jealousy and possessiveness: Perpetrators who kill or severely injure their partners are often possessed by the desire to own and control their partners, sometimes regarding every man around their partner as a rival and constantly accusing her of infidelity.
  • Extremely patriarchal concepts and attitudes,such as that a woman or girl must obey her husband or father who is the head of the family or comply with rigid concepts of honour and sexuality.
  • Persecution and psychological terror (stalking): Many perpetrators are not willing to accept a separation from their partner and try to prevent it by all means, including violence. This may lead to acts of violence and threats committed even many years after a separation.
  • Danger for children:Children are also at particular risk during separation and divorce. Abuser’s aggression against the partner may also extend to the children, and he may take revenge by abusing or killing them. Therefore, safety planning must always include the children.
  • Non-compliance with restraining orders by courts or police indicatea high-risk situation because it shows that the perpetrator is not willing to change his behaviour.
  • Possible triggersthat may lead to a sudden escalation of violence include changes in the relationship, for instance when the woman takes a job against the partner’s will, seeks help or files for divorce.

3.4.2 Undertaking a risk assessment

Risk assessment enables criminal justice authorities to decide on actions against the perpetrator. It also enables health care professionals and other service providers to support the patient in identifying measures to increase her safety and to raise her awareness of the risk (WAVE 2013).

A number of standardized risk assessment tools have been developed to assess the risk of repeating or escalating violence. One of the most commonly used tools to assess the danger of a woman being killed by a current or former partner used is Danger Assessment by Campbell (2004). It consists of two elements: 1) a calendar, on which the woman should mark frequency and severity (on a scale from 1-5) of violent incidents that happened in the past year; and 2) a list of 20 questions, to be answered with yes or no. Questions address significant risk factors, such as separation, use of a gun, or abuse during pregnancy, as well as factors that point to a lower risk (such as having never lived together or having never been pregnant by the perpetrator). For a copy of the Danger Assessment Tool, refer to the training package (part II, module 8).

Considerations for undertaking risk assessment (WAVE 2013):

  • Health care professionals should undergo training on applying risk assessment tools.
  • It is of utmost importance to ask the survivor about her own assessment of the situation. Any risk assessment tools should not be a substitute for listening to her assessment of the situation.
  • Many existing risk assessment tools focus on high-risk cases. A lower level of risk should not be used as basis to deny survivors access to services.
  • Most existing risk assessment tools were adopted in North America and Western Europe. When applying them in EECA or other regions, adapting them to local contexts may be advisable.

Health professionals may find acronyms useful to memorize key factors or steps in assessing risks. An example used in the UK is “S P E C S S”, which stands for Separation, Pregnancy, Escalation of Violence, Cultural Factors, Stalking and Sexual Assault (Department of Health undated, see box 21). This list of risk factors is non-exhaustive. Health facilities in the EECA region may want to consider creating localized acronyms, suitable to local languages and regional contexts.

Box 21: Example of an acronym to remember risk factors: S P E C S S

3.4.3 Supporting the patient in developing a safety plan

Safety planning is part of the overall process of risk management, which aims at preventing violence by influencing risk factors and protective factors. Safety planning seeks to improve the survivor’s resources – both dynamic (i.e. the social environment) and static (i.e. the physical environment, such as locks, video cameras, etc.) (WAVE 2013).

Developing  a safety plan may help the woman prepare to leave the relationship safely in case the violence escalates. The health provider should help the woman find out if there are affordable safe places that she can go to, such as homes of friends or relatives. They may be referred to women's shelters or women's organizations that can help them, in places where such facilities exist. Developing such a safety plan may prove difficult in the case of low-income women, especially those from rural or ethnic minority communities, who may not have the resources to leave the abuser and, in the absence of shelters, may not have access to or even be able to afford temporary stays in hotels or guest houses. Health facilities should take the initiative to network with such organizations and establish referral pathways to facilitate further support to help women experiencing intimate partner violence (WHO 2005; for more information on referrals see chapter 4). In the absence of shelters, health facilities should consider practical solutions, such as offering women short-term stays in the facility.

The check list provided in box 22 provides further guidance to health professionals when developing a safety plan together with the patient.

Box 22: Check list for developing a safety plan with the survivor.

  • Identify one or more neighbours you can tell about the violence, and ask them to help if they hear a disturbance in your house.
  • Are there any friends or relatives you can trust and who could give you and your children shelter for a few days?
  • Decide where you will go if you have to leave home and have a plan to go there, even if you do not think you will need to leave.
  • If an argument seems unavoidable, try to have it in a room or an area that you can leave easily.
  • Stay away from any room where weapons may be available. If possible, get the weapons outside your home.
  • Practice how to get out of your home safely. Identify which doors, windows, elevator or stairwell would be best.
  • Have a packed bag ready, containing spare keys, money, important documents and clothes. Keep it at the home of a relative or friend, in case you need to leave your home in a hurry.
  • Devise a code word to use with your children, family, friends and neighbors when you need emergency help or want them to call the police.
  • Use your instincts and judgment. If the situation is dangerous, consider giving the abuser what he wants to calm him down. You have the right to protect yourself and your children.
  • Remember, you do not deserve to be hit or threatened.
  • Supporting the patient in developing a safety plan

Source: adapted from Heise et al 1999

Please refer to the training package (part II, module 8) for a template for a simple safety plan that health professionals may go over together with the patient and help her to spell out resources and steps to increase her safety, such as packing a safety bag and noting where she keeps it, or identifying a code word that she can use with her children or neighbours so that they can call for help. Attention should also be paid to identifying a place where she can keep the safety plan without endangering her or her children’s safety.