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

A resource package

2.4. Barriers to an effective health care response to gender-based violence

Even though it has been widely acknowledged that the health sector plays a key role in the effective response to GBV, a number of barriers persist that prevent women survivors of GBV from receiving appropriate health care. Such barriers exist at the levels of both the patient who experienced GBV and the health care provider.

In order to overcome these barriers, changes in guidelines and policies, as well as in the daily work practices of health care professionals, are required. To this end, section 2.3.2, 2.3.3 and chapter 3 provide guidelines and recommendations.

Barriers faced by women survivors

The following reasons may prevent women who experienced GBV from accessing health care and disclosing violence to health professionals (adapted from Ganley 1998 and Hellbernd 2006, cited in PRO TRAIN 2009):

  • Shame, guilt, and the feeling to be solely or partly responsible for the violence suffered: A woman who experienced violence from an intimate partner may be convinced that she can stop the violence if she obeys the perpetrator’s wishes and “betters” herself.
  • Fear of reprisals from the perpetrator: Women who live in violent relationships may fear an escalation of violence and further threats, as violent partners usually forbid women to talk about the violence with any other person and threaten with further violence.
  • Fear of stigma and social exclusion by their families and communities.
  • Social isolation and the feeling of having to deal with the experienced violence all by themselves.
  • Long-term experiences of mistreatment that can damage women's self-confidence and self-esteem to such an extent that the search for and the acceptance of support becomes difficult.
  • Lack of safe options for their children and fear of losing child custody.
  • Fear of drawing attention to irregular immigration status or of losing status following separation from a violent spouse.
  • Lack of realistic options, e.g. for financial resources, housing, employment or safety.

Even though these barriers operate at the levels of partner relationships, families and the wider community and therefore require interventions beyond the health care system, health professionals nevertheless need to be aware of them, in order to be able to provide effective care and referrals to relevant service providers, such as shelters, crisis centres or counselling centres. These organizations may assist women in addressing some of these barriers, for instance through providing accommodation, legal counselling or other support.

Other barriers faced by women can and should be addressed by health care systems, including the following:

  • Lack of physical access to health care services for women living in remote areas.
  • Fear of negative responses from service providers and of being blamed for not separating from the abusive partner, in particular when the woman has received inappropriate and victim-blaming responses from other service providers in the past.
  • Not knowing which steps health care professionals will take, for instance whether police will be informed or whether the perpetrator will be approached.
  • Language and cultural barriers faced by migrant women and women belonging to ethnic minorities.
  • Situational aspects of the counselling and treatment situation, such as inappropriate physical conditions of the facility or insensitive behaviour of doctors and nursing staff.

Provider barriers to an effective health care response to GBV

The following barriers prevent health care professionals from identifying GBV as a cause of medical symptoms, from asking patients about violence and/or from providing effective care and support (adapted from Ganley 1998 and Hellbernd 2006, cited in PRO TRAIN 2009, IPPF 2010, Warshaw/Ganley 1996):

  • Insufficient knowledge about causes, consequences and dynamics of GBV:If health professionals do not ask about or do not recognize symptoms of GBV, they may misdiagnose survivors or offer inappropriate care.
  • Own attitudes and misconceptions about GBV that may result in perceiving intimate partner violence as a private matter or blaming the survivor for the violence.
  • Own experiences of GBV in the past.
  • Lack of clinical skills in responding to GBV. As a consequence, health care professionals may be reluctant to ask about GBV, so as to avoid "opening Pandora's box" (McCauley et al 1998, cited in PRO TRAIN 2009). Lack of knowledge and skills may also put the patient’s safety, life and wellbeing at risk, for instance when health professionals express negative attitudes to a patient who has been raped or by discussing a woman’s injuries in a way that can be overheard by a potentially violent spouse waiting outside.
  • Lack of information about existing support services and appropriate professional contacts, which could serve as a basis for referral.
  • Lack of time for medical care, as well as inadequate funding of counselling. It may be difficult to estimate how time-consuming a conversation would be and health care professionals are worried about having to cut back on the time needed for other patients.
  • Missing intra-institutional support such as standardized protocols, documentation forms or staff training on dealing with survivors of GBV.
  • Uncertainties about legal obligations, such as confidentiality rules or reporting obligations.
  • Absence of standard procedures, policies and protocols to ensure that health professionals’ response to all survivors of GBV follow standards of good clinical care.