M6C1&2 Violence And Child Abuse + Lecture on GBV, SAI, and CA Flashcards
What is the act defined as “violence against women and their children” as any act or series of acts committed by any person against a woman (his wife, former wife, or against a woman with whom the person has/had a sexual or dating relationship, or w whom he has a common child, or against her child; whether legitimate or illegitimate, inside or out the family abode, which results in or is likely to result in abuse?
RA 9262 (2004)
Epidemiology of violence:
1 in 5
14%
1 in 25
1 in 10
4%
1 in 5 women age 15-49 physical violence
14% married women physical
1 in 25 women aged 15-49 forced first sexual intercourse
1 in 10 aged 15-49 sexual violence
4% pregnant experienced violence during pregnancy
Special protection of children against child abuse, exploitation and discrimination act
RA 7610
Act defining violence against women and their children, providing for protective measures for victims, prescribing penalties therefore and other purposes
RA 9262
Anti-violence against women and their children act of 2004
RA 9262
What is the cycle of violence in order?
BSER PH
Build-up phase Standover Explosion Remorse Pursuit Honeymoon
What phase may begin w normal relations but involves escalating tension (verbal, emotional, financial)?
Build-up phase
What is the behavior of the person who uses violence in relationships escalates to the pt that a release of tension in inevitable?
Stand over phase
Affected might feel they’re “walking on eggshells”
Stand over phase
What marks the peaks of violence in the rel?
Explosion
- release tension
- may be unable to deal w their anger any other way
Explosion
- ashamed of their behavior
- retreat and become withdrawn from the rel
- justify their actions to themselves, unaware they are actually addicted to the release they have just experienced
Remorse
- promises to victim never to be violent again
- make up for for their behavior
- change but not
● At this stage, the person who uses domestic and intimate partner violence in relationships promises to the victim never to be violent again.
● They may try to make up for their past behavior during this period and say that other factors have caused them to be violent, for example, work stress, drugs, or alcohol.
● The violent offender may purchase gifts, and give the person affected attention.
● Also, the violent offender may go into such a dramatic personality change.
● The person affected by the violence will feel hurt, but possibly relieved that the violence is over.
Pursuit
- denial as to how bad the abuse and violence was
- ignore possibility that it will occur again
Honeymoon phase
Effects of DomVi:
- withdrawal/isolation
- difficulty gain, maintain, adjust to employment
- self medicating to cope
- avoidance
- loss of parenting skills
Behavioral
Effects of DomVi:
- poor hygiene
- loss of interest
Social
Physical injuries Hearing loss Vision loss Miscarriage or early delivery STD Knife/gunshot wounds Homicide Suicide
Immediate health impacts
Gastrointestinal dis ass w stress Headache Back pain Seizures Gyne prob Anxiety Depression Eating dis PTSD Sleep disturbances Smoke throughout preg Alcohol or subs misuse Suicide Homicide
Long-term health impacts
Respect for women’s human rights
Life Self determination Highest attainable std of health Non-discrimination Privacy and confidentiality Information
What are the 4 major steps to provide appropriate care to women being subjected to violence?
Awareness about violence against women
First-line support
Additional care for physical health
Additional care for mental health
What are the first line support that involves 5 tasks?
Listen Inquire abt needs and concerns Validate - understand & believe Enhance safety Suppot
What has the purpose to give them a chance to say what she wants in a safe and private place and impt for emotional recovery?
Listen
What has the purpose to learn what is most impt for the woman?
Inquire abt needs and concerns
Evidence of sexual assault is collected with how many days?
5 days
What does hx taking include?
1) general medical information
2) questions abt the assault
3) a gynecological hx
4) assessment of mental state
What complications may require urgent hospitalization?
Extensive injury (genitals, head, chest, abdomen) Neurological deficits (can't speak, probs walking) Respiratory distress Swelling of joints on one side of body (septic arthritis)
What are the 2 kinds of pills commonly used for emergency contraception?
- Levonorgestrel-only
2. Combined estrogen-progesterone
What EC works better and causes less nausea and vomiting?
Levonorgestrel-only 1.5mg
What is the dosage of combined estrogen-progesterone?
2 doses of 100ug ethinyl estradiol plus 0.5 levonorgestrel, 12 hrs apart
What can be taken at different times and along w food to reduce nausea?
EC and antibiotics
If the victim’s last menstrual pd began w/in 7 days before the attack, can she be pregnant?
Not likely
EC pills work mainly by what?
Stopping release of egg
Will EC pills prevent the next time she has sex?
Nope
When can you take EC pills?
Up to 5 days after the sexual assault, they become less effective w each day that passes
What are side effects of EC pills?
Nausea and vomiting
Also spotting or bleeding
What if she vomits EC pills 2 hrs after taking them?
Take another dose
If she is taking combined pills for EC, what can she take to reduce nausea?
Meclizine hydrochloride 30 mins to 1 hr before the EC pills
What is taken to prevent HIV, but should start asap up to 72 hrs after possible HIV exposure?
Post-exposure prophylaxis (PEP)
Follow-ups should be taken when?
2 wks, 1 month, 3 mos, and 6 mos after assault
What follow up visit is this?
STI: give 2nd hep B vaxx, if need. Remind her of the 6-month dose
MENTAL HEALTH: cont first-line support care
PLANNING: make next routine follow-up appointment for 3 mos after assault
1-month follow-up visit
What follow up visit is this?
STI: offer HIV test and counseling, make sure pre and post-test counseling is available and refer HIV prev, care and tx
MENTAL HEALTH: cont first-line support care
PLANNING: make next routine follow-up appointment for 6 mos after assault, also remind her of 6-month hepa B vaxx if needed
3-month follow-up visit
What follow up visit is this?
STI: offer HIV test and counseling if not done before, make sure pre and post-test counseling is available and refer HIV prev, care and tx; give 3rd dose hepa B vaxx if need
MENTAL HEALTH: cont first-line support care PLUS additional care for MH
6-month follow-up visit
a. offer LIVES
b. explain she’ll be better w time
c. strengthen positive coping mechanisms
d. explore availability of social support
c. stress redxn exercises
f. follow up
Basic psychosocial support - sufficient for first 1-3 mos
What do you take note in assessing MH status?
Appearance and behavior
Mood
Speech
Thoughts
The decision to treat for mod-severe depressive d/o should be made only if the woman has persistent symptoms over at least how many weeks?
Over 2 wks and can’t fxn in normal activities
What are typical presenting complaints of depressive d/o?
- Low energy, fatigue, sleep probs
- Multiple physical symptoms w no clear cause (e.g., aches and pain)
- Persistent sadness or depressed mood; anxiety
- Little interest or pleasure in activities
What is the 3rd leading cause of death among adolescents worldwide?
Suicide
More than half of child abuse victims are aged what?
10-18 years old
1 out of 4 victims are aged what?
5 y.o.
What is the second most handled case in DSWD?
sexually abused children
What is the most handled case in DSWD?
abandoned/neglected children
What is the most common sexual abuse?
Rape, followed by incest and acts of lascivioousness
What are the most sexually exploited children as victims?
prostitution or cyber pornography
What includes the failure of a caregiver to provide an appropriate and supportive environment?
Emotional abuse
What is the failure to provide for the development of the child; in terms of health, education, emotional dev, nutrition, shelter, and safe living conditions?
Neglect
What is a prevalent form of abuse seen in very young children?
Shaking
What can result from a very rapid shaking of the infant?
Intracranial hemorrhages
Retinal hemorrhages
Small “chip” fractures at the major joints of the extremities
What are the long-term consequences of shaking a baby rapidly?
Mental ret
Cerebral palsy
Blindness
What is the leading cause of child abuse fatalities?
Head trauma
Using auscultation, performed before palpation, what can reveal if the child has sustained intraabdominal injury?
decreased or no bowel movements
What can be noted during palpation if the intestines, liver, or spleen have been ruptured?
guarding or abdominal muscle rigidity
Why does DIC screen need to be performed for px w intracranial injury?
bcs intraparenchymal damage can alter coagulation
Lab exam for pseudocyst
Pancreatic enz
Lab exam for intracranial and extracranial injury
MRI, CT scan on the head
Lab exam for intra-abdominal injuries
CT scan on the abdomen
Lab exam for cardiac injury
Cardica enz
What are the roles of the physician on child survivors?
A. Immediate stabilization
B. Physical exam and Hx taking
C. DD
D. Report and refer
What are the 3 Rs that are crucial to the care of the abused children?
Recognition
Reporting
Referral
What is any act of gender-based violence that results in, or is likely to result in, physical, sexual, or psychological harm or suffering to women, whether occurring in public or private life?
GBV
It include violence against men, provided the violence stems from a man’s gender identity or presentation.
GBV
Where this harmful practice of child marriage most common?
Sub-Saharan Africa
Child marriage often results in increase Morbidity & Mortality related to delivery and birth
Early pregnancy
Child marriage often results in loss of family support
Social isolation
Child marriage often results in limiting the girl’s opportunities due to
Interrupts schooling
Child marriage often results in also
Increases her risk of experiencing domestic violence
In most countries, the majority of girls were cut before age
5 y.o.
It is about revealing the experience of Sexual Harassment by women victimized by men of power and authority
“MeToo” international uprising
Social multiplier effects: impact on interpersonal relations and quality
of life
o Intergenerational transmission of violence
o Reduced quality of life
o Erosion of social capital
o Reduced participation in democratic process
- Completion of secondary education
- Delaying age of marriage to 18
- Women’s economic autonomy, access to skills training, credit, and employment
- Access to support group
- Social norms must promote gender equality
= Judicial, Security/Protection, Social and Medical, staffed with knowledgable, trained, and skilled personnel - Availability of safe spaces and shelter
PROTECTIVE FACTORS
Neurologic symptoms
- hearing and visual loss,
- headaches
- numbness, and tingling (even with seemingly good explanation)
- stroke in a young woman
Anti-Violence Against Women and Their Children Law
RA 9262
The Anti-Rape Law of 1997
RA 8353
Anti-Trafficking in Persons Act of 2003
RA 9208
Anti-Sexual Harassment Act of 1995
RA 7877
Magna Carta for Women
RA 9710
Anti-Child Abuse Act – Special Protection of Children Against Abuse, Exploitation and Discrimination Act
RA 7610
Safe Spaces Act
RA 11313
Which law applies? A mother forces her daughter to undress in front of a camera, while an elderly man in a western country watches, a pays the mother through Western Union.
RA 7610: Anti-Child Abuse Act – Special Protection of Children Against Abuse, Exploitation and Discrimination Act
Which law applies? A 16-year old girl from a rural area of Cebu travels with a group of girls, who are of the same age as her, to Manila. They are all promised good-paying employment in a restaurant, but upon arrival in Manila, they were all forced to work at night in a bar, as entertainers, and are forced to have sexual relations with customers of the bar.
RA 9208: Anti-Trafficking in Persons Act of 2003
Which law applies? The boss often puts his arm around the shoulder of his secretary and rubs her neck while she’s working at her desk.
RA 11313: Safe Spaces Act
or
RA 7877: Anti-Sexual Harassment Act of 1995
Which law applies? The carpenters at a construction site have the habit of whistling and shouting dirty words at young girls passing by.
RA 7877: Anti-Sexual Harassment Act of 1995 or RA 11313: Safe Spaces Act
What refers to any act or a series of acts committed by any person against a woman who is his wife, former wife, or against a woman with whom the person has or had a sexual or dating relationship, or with whom he has a common child, or against her child whether legitimate or illegitimate, within or without the family abode, which results in or is likely to result in physical, sexual, psychological harm or suffering, or economic abuse including threats of such acts, battery, assault, coercion, harassment, or arbitrary deprivation of liberty?
Anti-Violence Against Women & Their Children Act of 2004 (R.A. No.
9262)
What can be a learned behavior?
Intimate partner violence (IPV)
The pattern of signs and symptoms, such as fear and a perceived inability to escape, appearing in women who are physically and mentally abused over an extended period by a husband or other dominant individual.
BATTERED WOMAN SYNDROME
Psychological stages of battered woman syndrome
- Denial
- Guilt
- Enlightenment
- Responsibility
3 important reasons why women do not, or cannot, leave their violent partners
- Practical difficulties in effecting separation
- Fear of retaliation
- The effects of severe abuse on the victim
Barriers physicians face:
- Lack of education
- Fear of precipitating more violence
- Tyranny of time
- Isolation
- Office security & personal safety
- Testifying the court
CLINICAL EVALUATION
R: Remember
A: Ask
D Document
R: Review
Red flag signs for physical injuries
- Centrally located injuries
- Characteristic DV injuries–cigarette burns, bite marks, rope burns,
bruises, welts with the outline of a recognizable weapon - Bilateral injuries
- Defensive posture injuries
- Injuries inconsistent with the explanation given
- Injuries in various stages of healing
Investigators and the Court want to know about the following:
o Age of an injury
o How the injury was produced (mechanism)
o Amount of force required to produce the injury
o The circumstances in which the injury was sustained
o The consequences of the injury (needs broad-based comprehension of anatomical, physiological, pathological principles)
Causes of spouse abuse:
Cultural norms:
o Male domination
o Patriarchy
o Coverture
Fatal Outcome
Homicide
Suicide
Maternal mortality
AIDS-related
Nonfatal outcome
- Physical health
- Chronic conditions
- Mental health
- Negative health behaviors
- Reproductive health
Intrapersonal
- Individual psychotherapy
- Residential treatment
Interpersonal
- Couples’ therapy
- Resocialization
- Group therapy
What is the second most common skeletal injury with abuse?
Skull fractures
What may present with coma or seizures without obvious evidence of scalp trauma?
Shaken Baby Syndrome
retinal hemorrhage in up to 80%
o only seen in 3% of accidental head trauma cases
o can lead to blindness
Shaken Baby Syndrome
What is the second leading cause of death?
Abdominal trauma
Where can you refer the child abuse?
- DSWD
- Women and Children’s Protection Desk, Philippine National Police
- National Bureau of Investigation
- Commission of Human Rights
- Barangay (GAD focal)
- Women and Children’s Protection Center (Pink Center), VSMMC
o Disclosure is reversed under pressure
o Seen more when abuser is trusted parent/parent figure
o Society is more ready to believe that the child lied rather than the abuse happened
Retraction
Speculum is infrequently used in adolescents
and rarely used in prepubertal children for what?
External inspection
Tool for magnification and photo
documentation
Colposcope
▪ Patient lying supine with hips externally flexed and knees rotated
▪ Gently grasp the labia minora bilaterally, pulling downwards and outwards (traction)
What position?
Frog leg position
Prone in a kneeling position while maintaining
contact on the head and chest.
What position?
Knee chest position
- one of the most important structures to describe
- locations of injury describe by cloc postion
- hymenal diameter
Hymen
Circulating maternal hormones causes what?
Estrogenization of hymen
Estrogen Effect on Hymen
- hormonal influences decrease in childhood
- hormonal influences become obvious once again during puberty
o estrogen – thickened, redundant, and pale
Normal and Non specific vaginal findings
- Erythema
- hymenal bumps, ridges, tags
- V-shaped notches between 9:00 and 3:00 not extending to the base of the hymen
- Vulvovaginitis
- Labial agglutination
- Fissures
- Midline skin tags or folds
- Venous congestion minor anal dilatation
- Lichen sclerosis
ANOGENITAL FINDINGS MAY SUGGEST
Previous trauma to the hymen
o hymenal notch extending through >50% of the width of the hymenal rim
o hymenal rim narrowing
o significant anal dilatation (marked immediate anal dilatation to a diameter of >2cm, in the absence of predisposing factors, eg., chronic constipation, sedation, anesthesia, neuromuscular conditions
o significant anal scarring
Previous trauma to the hymen
o Acute abrasions, lacerations or bruising: labia, perihymenal tissues, penis, scrotum, perineum
o Acute lacerations, bruising, petechiae: hymen
o Absent hymenal membrane
o Scarring or fresh laceration of the posterior fourchette
o Anal laceration
Blunt force of penetrating trauma
Diagnostic of Trauma/Sexual abuse
- hymenal laceration
- posterior fourchette scarring
- healed transection
- tenting of the healed injury
Diagnostic of Trauma/Sexual abuse (male)
o Penile abrasions o Bites bruises o Urethral/anal discharge o STI o Scars
Incidence of reported that was sexually abused as a child
Approx. 20% women and 5-10% men
Physically abused: 25-50%
What is a society’s common fund of beliefs and behaviors, and its concepts of how ppl should conduct themselves?
Culture
Child abuse or maltreatment results to what?
Results in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust, or power.
This includes acts that have an adverse effect on the emotional health and development of a child, like restricting movements, denigration, ridicule, threats and intimidation,discrimination, rejection, and other non physical forms of hostile tx.
Emotional abuse
Most common cause of death in young children, w children in the first 2 years of life being the most vulnerable
Head trauma
One of the syndromes of child abuse;
Repeated and devastating injury to skin, skeletal sys or nervous system;
Includes children w multiple fractures of different ages, head trauma and severe visceral trauma, w evidence of repeated infliction; rare
Battered child
Manifestations of child neglect
Noncompliance w health care recommendations
Failure to seek appropriate health care
Food deprivation resulting to hunger
Failure of a child to physically thrive
Exposure to drugs
Inadequate protection from environmental dangers
Abandonment
Inadequate supervision
Poor hygiene
Deprived of education
Physical health consequences of child abuse
Abdominal/thoracic injuries
Brain injuries
Bruises and welts
Burns and scalds
CNS health consequences of child abuse
Disability
Fractures
Lacerations and abrasion
Ocular damage
Considered as evidence of neglect:
○ Abandonment
○ Inadequate supervision
○ Poor hygiene
○ Being deprived of an education
Information should be gathered in a non-accusatory but detailed manner. Other information that may be useful in the medical assessment of a suspected physical abuse includes:
○ Past Medical History
■ Trauma, hospitalizations, congenital conditions, chronic illnesses
○ Family History
■ Especially of bleeding, bone disorders, and metabolic or genetic disorders
○ Pregnancy History
■ Wanted/unwanted, planned/unplanned, prenatal care, postnatal complications, postpartum depression, delivery in non-hospital settings
○ Familial patterns of Discipline
○ Child temperament
■ Easy to care for or fussy child
○ History of Past Abuse to child, siblings, or parents
○ Developmental History of Child
■ Language, gross motor, fine motor, psychosocial milestones
○ Substance abuse by any caregivers or people living in the home
○ Social and financial stressors and resources, and
○ Violent interactions among other family members
Head trauma is the leading cause of child abuse fatalities. ● When compared with child victims of severe accidents,
children with abusive head trauma are more likely to have subdural and subarachnoid hematomas, multiple subdural hematomas of differing ages, more extensive retinal hemorrhages, and associated cutaneous, skeletal, and visceral injuries.
Cranial injuries
● Inflicted injuries that involve the heart are rare and severe.
● Rib fractures in infants are usually caused by forceful squeezing of the chest; posterior or lateral rib fractures or multiple rib fractures are especially predictive of abusive trauma
● Auscultation, performed before palpation, may reveal decreased or no bowel sounds if the child has sustained intra-abdominal injury.
● If the intestines, liver, or spleen have been ruptured, guarding or abdominal muscle rigidity may be noted on palpation.
● Abdominal bruising is often not seen, even with severe blows to the abdomen.
Thoracoabdominal injuries
● Careful palpation of the legs, arms, feet, hands, ribs, and head may reveal acute or healing (callus formation) fractures.
● If a fracture is suspected, surfaces should be carefully examined for “grab marks” that may indicate restraint or areas that were pulled or twisted to create the fracture; however, absence of such bruising does not exclude abusive mechanisms of injury.
● Soft tissue swelling, with or without bruising, may indicate more recent trauma.
● A complete neurologic assessment, including reflexes, cranial nerves, sensorium, gross motor, and fine motor abilities, should be conducted. Abnormalities may reflect current or past injuries to the central nervous system.
● Abused children may also have developmental disabilities because of deprivation in the home environment or other causes.
Skeletal injuries
What is a particularly helpful tool in understanding the overall pattern of abusive and violent behaviors, which are used by a batterer to establish and maintain control over his partner?
Power and Control diagram
○ depression
○ feelings of hopelessness
○ numbness
○ anxiety
○ low self esteem
○ grief
○ shame
○ self blame
○ fear
○ confusion or trouble concentrating
○ anger
Emotional effects of domvi
○ isolation from family and friends
○ difficulty trusting others, even family and friends
○ loss of interest
○ poor hygiene
○ little support
Social effects of domvi
○ sleep deprivation
○ somatic, stomach and headaches
○ chronic health problems
○ problems due to substance abuse
○ injuries due to abuse
Physical effects of domvi
This means being aware of how differences in power between women and men determine the way that men and women treat each other, their access to resources to protect their health and often how the health system treats them.
Gender sensitivity
What refers to ongoing or past violence and abuse by an intimate partner or ex-partner - a husband, boyfriend, or lover, either current or past. Women may suffer several types of violence by a male partner: physical violence, emotional/psychological abuse, controlling behaviours, and sexual violence?
IPV
You may suspect that a woman has been subjected to violence if she has any of the following:
○ Ongoing emotional health issues, such as stress, anxiety or depression
○ Harmful behaviors such as misuse of alcohol or drug
○ Thoughts, plans or acts of self-harm or (attempted)
suicide
○ Injuries that are repeated or not well explained
○ Repeated sexually transmitted infections
○ Unwanted pregnancies
○ Unexplained chronic pain or conditions (pelvic pain or
sexual problems, gastrointestinal problems, kidney or
bladder infections, headaches)
○ Repeated health consultations with no clear diagnosis.
WHAT TO DO IF VIOLENCE IS SUSPECTED?
● Never raise the issue of partner violence unless a woman is alone. Even if she is with another woman, that woman could be the mother or sister of an abuser.
● If you do ask her about violence, do it in an empathic, non-judgmental manner. Use language that is appropriate and relevant to the culture and community you are working in. Some women may not like the words “violence” and “abuse”. Cultures and communities have ways of referring to the problem with other words. It is important to use the words that women themselves use.
● The job aid on the next page provides examples of the type of statements and questions you can use to ask about intimate partner violence.
○ Not allowing a woman to go out of the home, or to see family or friends
○ Insisting on knowing where she is at all times
○ Often being suspicious that she is unfaithful
○ Not allowing her to seek health care without
permission
○ Leaving her without money to run the home.
Controlling behavior
○ Criticizing her repeatedly
○ Calling her names or telling her she is ugly or stupid
○ Threatening to hurt her or her children
○ Threatening to destroy things she cares about
○ Belittling or humiliating her in public.
Emotional or psychological
○ Forcing her to have sex or perform sexual acts when
she doesn’t want to
○ Harming her during sex
○ Forcing her to have sex without protection from
pregnancy or infection
Sexual violence
refers to forced sex or rape; it can be by someone a woman knows (partner, other family member, friend or acquaintance) or by a stranger.
Sexual assault
Documenting Partner violence
Documenting is important to providing ongoing sensitive care, to remind yourself or to alert another provider at later visits. Documentation of injuries could be important if the woman decides to go to the police.
○ Tell her what you would like to write down and why. Ask her if this is okay with her. Follow her wishes. If there is anything she does not want written down, do not record it.
○ Enter in the medical record any health complaints, symptoms, and signs, as you would for any other woman, including a description of her injuries. It may be helpful to note the cause or suspected cause of these injuries or other conditions, including who injured her.
○ Do not write anything where it can be seen by those who do not need to know, for example on an X-ray slip or a bed chart.
○ Be aware of situations where confidentiality may be broken. Be cautious about what you write, where and where you leave the records.
○ For greater confidentiality, some facilities use a code or special mark to indicate cases of abuse or suspected abuse.
What is the most important of good communication and the basis of first-line support. It involves more than just hearing the woman’s words?
It means:
○ Being aware of the feelings behind her words
○ Hearing both what she says and what she does not
say
○ Paying attention to body language-both hers and
yours-including facial expressions, eye contact,
gestures
○ Sitting or standing at the same level and close enough to the woman to show concern and attention but not
so close as to intrude
○ Through empathy, showing understanding of how the woman feels.
Listen
Purpose: To learn what is most important for the woman. Respect her wishes and respond to her needs. As you listen to the woman’s story, pay particular attention to what she says about her needs and concerns - and what she doesn’t say but implies with words or body language. She may let you know about physical needs, emotional needs or economic needs, her safety concerns or social support she needs. You can use the techniques below to help her express what she needs and to be sure that you understand.
Inquire about her concerns
● Purpose: To let her know that her feelings are normal, that it is safe to express them and that she has a right to live without violence and fear.
VAlidating another’s experience means letting the person know that you are listening attentively, that you understand what she is saying, and that you believe what she says without judgment or conditions.
● Important things that you can say:
○ “It’s not your fault. You are not to blame.”
○ “It’s okay to talk.”
○ “Help is available.” (Only if it is true.)
○ “What happened has no justification or excuse.”
○ “No one deserves to be hit by their partner in a
relationship.”
○ “You are not alone. Unfortunately, many other women
have faced this problem too.”
○ “Your life, your health, you are of value.”
○ “Everybody deserves to feel safe at home.”
○ “I am worried that this may be affecting your health.”
● The following job aids suggest some ways that you can help women deal with various emotions and reactions.
Validate
Purpose: To help a woman assess her situation and make a plan for her future safety. Many women who have been subjected to violence have fears about their safety. Other women may not think they need a safety plan because they do not expect that the violence will happen again. Explain that partner violence is not likely to stop on its own. It tends to continue and may over time become worse and happen more often.
● Assessing and planning for safety is an ongoing process - it is not just a one-time conversation. You can help her by discussing her particular needs and situation and exploring her options and resources each time you see her, as her situation changes.
Enhance safety
Purpose: to connect a woman with other resources for her health, safety, and social support
○ Women’s needs generally are beyond what you can provide in the clinic. You can help by discussing the woman’s needs with her, telling her about other sources of help, and assisting her to get help if she wants
Support
There are many reasons that women stay in violent relationships. It is important not to judge her and not to urge her to leave. She has to make that decision herself in her own time. Reasons for not leaving include
○ She depends on her partner’s income. In some societies it is difficult for a woman to earn her own living.
○ She believes that children should be raised with a father and thinks that her own welfare is less important than this ideal.
○ She thinks that violence is normal in relationships and that all men will be violent and controlling.
○ She fears an extreme violent reaction to her leaving.
○ Her self-esteem is low and she believes that she
cannot manage on her own
○ She feels that she has no place to go or no one to turn
to for support.
○ She still loves him and thinks he will change.
○ She thinks that he needs her.
○ She does not want to be alone
○ She is afraid of being abandoned by the community for having left her partner.
Hx taking includes
○ General medical information
○ Questions about assault (only ask what is
needed for medical care e.g. penetration, oral,
vaginal, anal)
○ A gynecological history
○ An assessment of mental state
History
A.1 Ask about general medication: General medication information should cover any current or past health problems, allergies and any medications that the woman is taking
A.2 Talk about the assault: the reason to obtain an account of the violence is to:
● Guide the exam so that all injuries can be found and treated
● Assess her risk of pregnancy, STId and HIV
● Guide specimen collection and documentation
Politely ask the woman to briefly describe the events. Do not force a woman to talk about the assault if she does not want to. In all cases limit questions to just what is required for medical care. However, if a woman clearly wants to talk about what happened, it is very important to listen empathetically and allow her to talk.
A.3 Take a gynecological history: The purpose of taking a gynecological history is to:
● Check the risk of pregnancy and STIs
● Check whether any exam findings could result from
previous traumatic events, pregnancy or delivery
A.4 Assess mental health: Ask general questions about how she is feeling and what her emotions are while taking her history
DO A HEAD-TO-TOE EXAMINATION, INCLUDING GENITO-ANAL EXAM
● The main reason for the physical examination is to determine what medical care is needed. It is also used to complete any legal documentation.
○ Assure her that she is in control. She can ask questions, can stop the exam at any time and can refuse any part of the exam.
○ Look at the woman before you touch her and pay attention to her appearance and emotional state.
○ At each step of the exam, tell her what you are going to do, and ask her permission first
○ Ask often if she has any questions and if you can proceed.
● Examine
○ Make sure equipment and supplies are prepared.
○ Take the patient’s vital signs - pulse, blood pressure, respiratory rate and temperature.
○ Work systematically, be unhurried and give time to the examination.
○ Record all your findings and observations clearly and fully on a standard exam form
○ Document carefully and fully any injury or other mark
as this can be important evidence
● Do genito-anal examination
○ In cases of sexual assault, a genito-anal examination is necessary. This is a sensitive examination, particularly the speculum exam
■ Help the woman feel as comfortable as possible.
■ Let her know when and where you will touch her
■ Help the woman to lie on her back with her legs
bent, knees comfortably apart.
■ Place a sheet over her body. It should be drawn up at the time of the examination.
■ Work systematically. Have a good light source to
view injuries and record findings
● STIs: check that woman has completed the course of any medications given
● Check adherence to PEP, if she is taking it
● Discuss any test results
● Pregnancy: test for pregnancy if she was at risk; if she is
pregnant, tell her about the available options
● Mental Health: continue first-line support and care
○ Assess the patient’s emotional state and mental status
○ If any problems, plan for psycho-social support and
stress management, such as progressive relaxation or
slow breathing.
○ Make next routine follow-up appointment for 1 month
after the assault
2 week follow up visit
● STIS- give second hep B vaccination, if needed. Remind her of the 6-month dose.
● MENTAL HEALTH-continue first-line support and care.
○ Assess her emotional state and mental status.
○ Ask if she is feeling better
○ If new or continuing problems persist, plan for
psycho-social support and stress management.
○ For depression, alcohol or substance use, or
post-traumatic stress disorder, refer to specialized
care with good understanding of sexual violence.
● PLANNING
○ Make the next routine follow-up appointment for 3 months after the assault.
1 month FUV
● STIS- offer HIV testing and counseling
○ Make sure that pre- and post-test counseling is
available and refer for HIV prevention, treatment and
care.
● MENTAL HEALTH -continue first-line support and care.
○ Assess her emotional state and mental status
○ If new or continuing problems, plan for psycho-social
support and stress management.
○ For depression, alcohol or substance use, or
post-traumatic stress disorder, refer to specialized
care with good understanding of sexual violence.
● PLANNING
○ Make the next follow-up appointment for 6 months after the assault.
○ Also, remind her of the 6-month dose of Hepatitis B vaccine, if needed
3 month FUV
● STIS - offer HIV testing and counseling if not done before
○ Make sure that pre- and post-test counseling is
available and refer for HIV prevention, treatment and
care.
○ Give third dose of hepatitis B vaccine, if needed.
● MENTAL HEALTH- continue first-line support and care.
○ Assess the patient’s emotional state and mental
status.
○ If there are new or continuing problems, plan for
psycho-social support and stress management.
○ For depression, alcohol or substance use, or
post-traumatic stress disorder, refer to specialized care with good understanding of sexual violence.
6 month FUV
IMMINENT RISK OF SUICIDE AND SELF-HARM
● Some health care workers fear that asking about suicide may provoke the woman to commit it.
● On the contrary, talking about suicide often reduces the woman’s anxiety around suicidal thoughts and helps her feel understood.
● If she has:
○ Current thoughts or plan to commit suicide or to harm
herself, OR
○ a history of thoughts or plans for self-harm the past
month or acts of self-harm in the past year, and she is now extremely agitated, violent, distressed or uncommunicative.
● then there is immediate risk of self-harm or suicide and she should not be left alone.
● Refer her immediately to a specialist or emergency health facility.
MODERATE-SEVERE DEPRESSIVE DISORDER
● Women who have suffered intimate partner violence or sexual assault may feel extreme emotions of continuing fear, guilt, shame, grief for what they have lost, and hopelessness.
● These emotions, however overwhelming, are usually temporary and are normal reactions to recent difficulties.
● When a woman is unable to find a way to cope and these symptoms persist, then she may be suffering from mental disorders such as depressive disorder.
● People develop depression even when not facing extreme life events.
● Any community will have people with pre-existing depressive disorder.
● If a woman has suffered from such a depressive disorder before experiencing violence, she will be much more vulnerable to having it again.
● Note: The decision to treat for moderate-severe depressive disorder should be made only if the woman has persistent symptoms over at least 2 weeks and cannot carry out her normal activities
Typical Presenting Complaints of Depressive Disorder
● Low energy, fatigue, sleep problems
● Multiple physical symptoms with no clear (for example
aches and pains)
● Persistent sadness or depressed mood; anxiety
● Little interest in or pleasure from activities.
Why do we call it the Power and Control Wheel?
● Battering is one form of domestic or intimate partner violence.
● It is characterized by the pattern of actions that an individual uses to intentionally control or dominate his intimate partner.
● That is why the words “power and control” are in the center of the wheel.
● A batterer systematically uses threats, intimidation, and coercion to instill fear in his partner.
● These behaviors are the spokes of the wheel.
● Physical and sexual violence holds it all together - this
violence is the rim of the wheel.
The cycle of violence
● The theory that domestic violence occurs in a cycle was developed in 1979 by Lenore Walker as a result of a study conducted in the United States.
● The cycle of violence theory explains how and why the behavior of a person who commits domestic or intimate partner violence (IPV) may change so dramatically over time.
● The cycle of violence theory also provides an understanding of why the person affected by domestic and family violence continues to face a violent situation.
● The cycle goes through a number of stages.
● However, it is acknowledged that it is not the same for
everyone and some people may experience only some stages of the cycle and cycles can different in length for some.
Anti rape law of 1997
RA 8353
Safe spaces act
RA 11313
Anti-sexual harassment act of 1995
RA 7877
