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

A resource package

11. Referral

This part of the training requires careful research and preparation from the organizer or trainer. As it is already stated on the checklist, any service available to the survivors of violence in the region should be identified before the training. The participants should get a list containing concrete contact details of the available services. However, if very few or no services are available to survivors of violence, the health care provider can develop a safety strategy together with the survivor - see at the bottom of this page.

If the patient feels it is safe to do so, the health professional can provide her with written information (including phone numbers) on legal options, local counseling and crisis intervention services, shelters, and community resources. Educational materials on domestic violence that are on display in waiting areas and examination rooms may help patients identify violence as a personal health problem.

Patients should be given both verbal and written referrals for support services which may include:

  • women´s helpline
  • crisis or counseling centers
  • shelters or safe houses
  • HIV/AIDS counseling
  • legal aid
  • support groups
  • therapists
  • financial assistance agencies
  • social service agencies

The types of referrals given will vary depending on availability and the patient’s individual needs and circumstances, and also on the availability of facilities and resources. Health care providers should be familiar with the full range of formal and informal resources that are available locally for survivors of sexual violence. It is the role of the health care worker to help patients identify and choose the most suitable option(s) for their particular requirements.

Health workers may be required to provide a certificate for absenteeism from school or work; these should be non-specific as to the reason for the absence (i.e. not stating that the patient was sexually assaulted). Information regarding sexual violence, and about support services for survivors in particular, should be readily accessible; strategies that might be helpful in this regard include:

  • Compile a list of local services and telephone numbers that can be kept in a place that is easily accessible.
  • Display posters about gender based violence and where to go for help on the walls of health facilities (having information prominently displayed may make survivors feel more comfortable in disclosing and talking about the sexual violence in their lives).
  • Place pamphlets and brochures regarding sexual violence in examination rooms and women’s toilets so that patients can take them away with them or read the information in private.
  • Develop small pocket-size materials with lists of useful telephone numbers and addresses.

Source: adapted WHO Guidelines for Medico-legal Care of Victims of Sexual Violence

Developing Safety strategies with the survivor

Health care providers can help women experiencing violence by developing a 'safety plan' with them. Especially when there are very few services like shelters or helpline available, health professionals can sit down with the survivor and brainstorm with her about resources she can use to keep herself safe. Below you can download a template to help the health workers develop a safety plan together with the survivors.

The list below provides issues to discuss with the women, whether or not they are thinking of leaving the abusive relationship. They can then draw on these issues to develop their own specific safety plan as appropriate. Developing a safety plan may help the woman prepare to leave the relationship safely in case the violence escalates. Developing such a safety plan could prove much more 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 may not have access to or even be able to afford temporary stays in hotels or guest houses.
The health provider may have to find out if there are affordable safe places that the woman can go to, such as homes of friends or relatives. They may be directed to women's shelters or women's organizations that can help them, in places where such facilities exist. Community-based women's groups, such as self-help and microcredit groups, have the potential to provide both financial and psychological support to a woman who wishes to leave a violent relationship. Health facilities could take the initiative to network with such groups and harness their support to help women experiencing intimate partner violence. In the absence of shelters or women's groups and organizations, the health provider may be in a difficult situation, wanting to help but having limited possibilities to do so.
Lessons to date however indicate that, in all circumstances, it is worthwhile to at least talk to the woman, acknowledge and document her situation of abuse and provide whatever help is within the provider's means.

Developing a safety plan together with the survivor:

  • Identify one or more neighbors 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.

Adapted from: Heise L, Ellsberg M, Gottemoeller M. Ending violence against women. Population Reports, Volume XXVI, No. 4, December 1999.

Exercise: How to work with a “Referral” and a “Safety Plan”
Timeframe: exercise with role play 15 minutes, 30 minutes discussion
Aim: To response appropriately to disclosures of violence
Method: role play
Exercise description:
Worker develops a personal safety plan with the survivor. Role play based on the handout: personal safety plan. Observer gives her/his comments after the role play.
Situation: The survivor has arrived at the health center to ask for advice. The staff member/worker will develop a safety plan with the survivor. Discussion and development of plan takes about 15 minutes (=based on practice experience).
Parties: Survivor, health professional, observer
Group discussion after the role play: Survivor/ health professional /observer: Comments or questions etc.
Gather results on a flipchart at the end of the role play: How useful is the safety plan?

  • Useful questions
  • Questions that were not useful

Notes for trainer:
One member of each pair plays the survivor and the other plays the staff member/worker. There should be an observer to give feedback at the end. A bigger training group can be divided into small groups of three persons. Parties can change roles, if there is enough time.