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

A resource package

3.1. Identifying gender-based violence

Even though survivors of GBV are more likely than the general population to use health services, they are not likely to spontaneously disclose. Research indicates that when health care professionals sensitively enquire if a women shows symptoms that can indicate GBV, this can increase the chances of disclosure (NHS 2010, Feder et al 2011); for an example of a UK-based intervention in a general practice setting, see chapter 4, box 24). Therefore, facilitating a positive disclosure of GBV is an important starting point for any health care intervention. Asking about GBV, when done in a professional and supportive manner, can help to break the feelings of isolation, guilt and shame that survivors of violence may experience and to convey the message that help is available and that she may use it, if she feels ready (Warshaw/Ganley 1996).

This sub-chapter introduces the concepts of routine enquiry and clinical enquiry (section 3.1.1). It aims to support health care professionals in understanding clinical conditions associated with GBV (section .3.1.2), in setting up a safe space to ask the patient about GBV (section 3.1.3) and in asking questions to a woman who presents with conditions that may be caused by GBV (section 3.1.4). section 3.1.5 presents resources that health facilities can provide to assist health care providers in asking about GBV, as well as to encourage survivors to disclose GBV to the health care provider.

3.1.1 Routine enquiry versus clinical enquiry

In health care settings, two approaches can be distinguished in facilitating the disclosure of intimate partner violence:

  • Routine enquiry (also referred to as screening or universal screening), i.e. routinely asking women presenting in health care settings about exposure to intimate partner violence.
  • Clinical enquiry (or case-finding), i.e. asking women presenting in health care settings based on clinical conditions, the history and the examination of the patient (WHO 2013).

Routine enquiry is not recommended (WHO 2013 Recommendation 2). This is because even though this method has shown to increase rates of identification, it has neither reduced intimate partner violence nor led to any notable benefit for women’s health. Instead, clinical enquiry is advised; health professionals should ask about exposure to intimate partner violence when assessing conditions that may be caused or complicated by violence, in order to improve diagnosis/identification and subsequent care(WHO 2013 Recommendation 3). See section 3.1.3 for minimum conditions that should be observed when asking about GBV.

However, routine enquiry might be considered in specific circumstances:

  • Women presenting with mental health symptoms and disorders (depression, anxiety, PTSD, self-harm/suicide attempts) due to the strong correlation between mental health disorders among women and intimate partner violence.
  • HIV testing and counseling- since intimate partner violence may affect the disclosure of HIV status, or jeopardize the safety of women who disclose, as well as their ability to implement risk-reduction strategies.
  • Antenatal care- because of the dual vulnerability of pregnancy and also taking into account the possibility of follow-up in antenatal care (WHO 2013).

3.1.2 Understanding the signs of gender-based violence

The following list presents symptoms that should make health professionals consider asking about GBV, in particular intimate partner violence.

Box 15: Examples of clinical conditions associated with intimate partner violence

Symptoms of depression, anxiety, PTSD, sleep disorders

  • Suicidality or self-harm
  • Alcohol and other substance use
  • Unexplained chronic gastrointestinal symptoms
  • Unexplained reproductive symptoms, including pelvic pain, sexual dysfunction
  • Adverse reproductive outcomes, including multiple unintended pregnancies and/or terminations, delayed pregnancy care, adverse birth outcomes
  • Unexplained genitourinary symptoms, including frequent bladder or kidney infections or other
  • Repeated vaginal bleeding and sexually transmitted infections
  • Chronic pain (unexplained)
  • Traumatic injury, particularly if repeated and with vague or implausible explanations
  • Problems with the central nervous system – headaches, cognitive problems, hearing loss
  • Repeated health consultations with no clear diagnosis
  • Intrusive partner or husband in consultations

Source: adapted from Black 2011, cited in WHO 2013

Apart from clinical symptoms, health care professionals should also be aware that certain types of behaviours observed with female patients can be indicators of exposure to intimate partner violence.

Box 16: Examples of behaviours that may indicate intimate partner violence

  • Frequent appointments for vague symptoms
  • Injuries inconsistent with explanation of cause
  • Woman tries to hide injuries or minimize their extent
  • Partner always attends unnecessarily
  • Woman is reluctant to speak in front of partner
  • Non-compliance with treatment
  • Frequently missed appointments
  • Multiple injuries at different stages of healing
  • Patient appears frightened, overly anxious or depressed
  • Woman is submissive or afraid to speak in front of her partner
  • Partner is aggressive or dominant, talks for the woman or refuses to leave the room
  • Poor or non-attendance at antenatal clinics
  • Early self-discharge from hospital

Source: Department of Health 2005

It is important to keepin mind that none of the above signs automatically indicate that a patient has experienced GBV. However, they should raise suspicion and prompt health professionals to try to see the woman in private to ask her if she has experienced violence. Even if she chooses not to disclose at this time, she will know that the health care provider is aware of the issue and she might choose to approach the care provider at a later time(Department of Health 2005).

3.1.3 Minimum requirements for asking about GBV

When enquiring about GBV, health care facilities and providers need to ensure that a number of minimum requirements are in place. In particular, this requires that (WHO 2013):

  •  A protocol or standard operating procedure is in place to guide the intervention.
  • Health care providers are trained on the correct way to ask and how to respond to women who disclose.
  • Health care providers have ensured that it is safe to ask about GBV (see figure 4 below), including privacy and confidentiality of the consultation.
  • A system for referral is in place.
  • Health care providers are aware and knowledgeable about resources to refer women to.

Health care professionals may use the following criteria to determine whether it is safe to ask about GBV (see also figure 4 below):

  • Ensuring a private and confidential space is an important first step to consider, especially in the context of hospital-based health care providers who may be seeing a patient behind a fabric curtain. While curtains offer a visual barrier, it may still be possible for third persons to overhear the conversation.
  •  Health care providers should avoid asking a woman about GBV in the presence of a family member, friend, or child over 2 years. While health care staff may feel that it is positive that the patients get support from a family member or friend, they should keep in mind that intimate partners, other family members or friends can be partaking in the abuse. Perpetrators may also use children accompanying the patient to obtain information.
  • For women who are migrants, refugees or belong to an ethnic minority and do not speak the local language, health care providers should ensure the presence of a professional translator (see box 17).

Box 17: Recommendations for working with interpreters in health care settings

  • Avoid using family members as interpreters. While this might seem to be an option because of limited financial resources or unavailability of professional interpreters in a certain language, it can put women at risk and should therefore be avoided. When using a family member as the interpreter is the only option, health care staff should not enquire about GBV. Health facilities could consider preparing a list of multilingual staff that can help with interpretations.
  • Ensure that patient is comfortable with using the interpreter. Health care professionals should keep in mind that in small communities (e.g. among deaf women or groups using minority language) the translator might be able to identify the woman through providing interpretation services and then pass on the information to the perpetrator.
  • Ensure that the interpreter is trained to interpret around issues of GBV. This will not only help to ensure a non-judgemental and professional approach, but also accuracy of terms used, keeping in mind that in some languages, terms like abuse, risk or counsellor can have different meanings The NGO Standing Together against Domestic Violence shared the following example: A health professional asked a woman if she wanted to be referred to a "counsellor" (i.e. psychological therapist). This was translated as "counsellor" in the meaning of local government official – a difference in meaning that may easily lead to irritation and lack of confidence in the support provided on the part of the patient

Source: Standing Together against Domestic Violence 2008

Figure 4: Is it safe to enquire about intimate partner violence? 


3.1.4 How to ask about gender-based violence

Asking a woman if she has experienced GBV is a difficult task. Health care professionals may be reluctant to ask because they are afraid of offending the patient, lack knowledge or confidence to bring up the issue of violence or do not know what to do next, after having opened “Pandora’s box”. At the same time, asking about GBV is very important. Research has shown that most women, even though they would not themselves start talking about violence, react positively to being asked (Stenson et al 2001, Bacchus et al 2002, Perttu 2005, all cited in Perttu/Kaselitz 2006).

Training health care professionals is crucial to increase their knowledge and confidence on asking about GBV and on the next steps of the intervention following, as shown in the following quote from a health care professional working at a hospital in Austria: “(Back) in 1997, I (…) attended a training programme on responses to violence against women. Until then, working as a nurse in the accident surgery outpatient clinic of Wilhelminen Hospital, I had not questioned statements by patients but simply accepted what they said: that they had fallen from a ladder or down the stairs, etc. During the training, I became aware for the first time that a number of injuries might have another cause and that it could be a good idea to ask further questions. (…) In one case, when I suspected that the patient had been abused I said on an impulse that her injuries were not consistent with what she had told us about her accident but that I rather thought she had been abused. The patient answered: ‘You are the first one to ask. I have often been to (two other hospitals in town) but nobody has ever shown any further interest in my case. I just received treatment. But you are the first one to ask me directly.’ Following this ‘success’ I have gradually become less reluctant to ask women directly whether they have experienced violence” (Federal Chancellery 2008).

Table 10: Tips for communicating with survivors of GBV – do’s and don’ts

When asking about GBV, it is advisable to begin the enquiry with an introductory question, explaining the patient that GBV affects many women and underlining the impact of violence on women’s health, before continuing with direct and more specific questions.

Examples of introductory questions:

  • “From my experience, I know that abuse and violence at home is a problem for many women. Is it a problem for you in any way?”
  •  “We know that many women experience abuse and violence at home and that it impairs their health. I wonder if you have ever experienced violence at home?”
  • “We know that violence against women is a very common problem. About 30% of women in this country are abused by their partners. Has that ever happened to you?”
  • “Some women think they deserve abuse because they have not lived up to their partners’ expectations, but no matter what someone has or hasn’t done, no one deserves to be beaten. Have you ever been hit or threatened because of something you did or didn’t do?”
  • “Many of the women I see as patients are dealing with abusive relationships. Some are too afraid or uncomfortable to bring it up themselves. Have you ever experienced violence from your partner?” (adapted from Perttu/Kaselitz 2006, Warshaw/Ganley 1996).

Examples of direct questions:

  • I am concerned that your symptoms may have been caused by someone hitting you. Has someone been hurting you?”
  • “According to our experience, women get these kinds of injuries when assaulted. Has someone assaulted you?”
  • “Did someone hit you? Who was it? Was it your partner/husband?”
  • “Has your partner or ex-partner ever hit you or physically hurt you or someone close to you?”
  • “Has your partner ever forced you to have sex when you did not want to? Has he ever refused to practice safer sex?”
  • “Does your partner frequently belittle you, insult you and blame you?”
  • “Has your partner ever tried to restrict your freedom or keep you from doing things that were important to you (like going to school, working, seeing your friends or family)?” (adapted from Perttu/Kaselitz 2006, Warshaw/Ganley 1996).

Health care professionals should make sure to raise questions and provide explanations in a manner appropriate to the survivors’ age, education, culture and level of tranquillity at the time. Depending on the local context, it may be advisable to avoid legal or technical terms like “domestic violence,” as the meaning might not be clear and some women might not identify with it, and instead circumscribe the violence, using commonly used terms.

3.1.5  Resources to facilitate a positive disclosure of gender-based violence

Displaying written information materials on GBV in health care settings can help to encourage women to speak about violence. This may be achieved through displaying posters in waiting or consultation rooms, containing a message encouraging survivors to raise violence in the medical consultation.  Further, health facilities should make pamphlets or leaflets  available in private areas such as women’s washrooms, to provide information on available services, such as shelters, helplines or legal advice, with appropriate warnings about taking them home if an abusive partner is there (WHO 2013 Recommendation 4).

Figure 5: Desk organizer – “You can talk to me about violence.”

Health facilities should also provide health care staff with information resources to help them memorize clinical indicators of GBV, tips for asking questions and other steps in the intervention chain. This may include laminated handouts or cards displaying simple flowcharts or stationary such as the ruler designed and produced by ANNA – National Center for the Prevention of Violence, which lists five key steps in identifying GBV and providing care for survivors (figure 6)

Figure 6: Reference Card: Helping Women Survivors of Domestic Violence