Helping victims of sexual coercion: provider's role depends on available resources and support.

KEY POINTS

* Reproductive health care providers may be able to offer counseling, medical, and referral services.

* Addressing nonconsensual sex and other forms of violence against women within reproductive health services can improve quality of care.

* Effective services require clear policies and procedures, positive provider attitudes toward victims, institutional support, and referral networks.

* Research is needed to determine the impact of provider interventions.

"When the physician told me that my health problems were related to what was happening in my house, I started to understand what was going on with me. It was as if a screen was lifted from my eyes, and I started to think that I did not deserve this."

--Survivor of intimate partner violence, the Dominican Republic 

This woman's experience illustrates how, by defining violence as a health threat, medical professionals can encourage victims of sexual coercion or of physical or psychological abuse by intimate partners to consider making positive changes in their lives. (1)

Reproductive health care providers are often particularly well placed to detect sexual coercion and to care for its predominantly female victims since many women routinely attend family planning or primary health care clinics. Reproductive health care providers also often see the effects of sexual coercion on their clients' health, such as recurrent sexually transmitted infections and unintended pregnancies. (2)

But providers in family planning clinics and other health facilities rarely have the knowledge, skills, resources, and support necessary to identify cases of sexual coercion; offer medical, counseling, and referral services to those who experience it; or document evidence of sexual assault.

"Sexual and reproductive health programs are largely premised on consensual sex," notes Dr. Shireen Jejeebhoy, a senior program associate in the Population Council's office in New Delhi, India, in a recent review of the nonconsensual sexual experiences of young people in developing countries. (3) "At the same time, programs that deal explicitly with nonconsensusal sex are often narrowly focused on improving the management of the few rape cases reported to the police."

Addressing sexual coercion more comprehensively within reproductive health and women's health care services poses challenges but also offers opportunities to improve quality of care. Providers who understand how sexual coercion can affect clients' health are more likely than others to provide relevant family planning and sexual risk-reduction counseling, and they are less likely to misdiagnose chronic complaints resulting from abuse. Strengthening services for victims of violence can also benefit clients because staff members are more aware of the need to protect clients' privacy and maintain the confidentiality of medical records. (4)

Challenges for providers

Providers are often reluctant to address sexual coercion or other forms of violence experienced by their clients. Perceived barriers to helping victims include an inability to spend enough time with clients, limited training and skills, lack of referral services or effective interventions, concern about legal consequences, and fear of offending clients. (5)

Many providers simply do not know how to help clients who have experienced sexual coercion. In South Africa, only about a quarter of 354 providers interviewed at hospitals and primary care centers had received any training in sexual assault services, and training that had occurred focused largely on medical and forensic issues, with little attention to psychosocial aspects or provider attitudes. (6)

Training should address providers' attitudes because it may be difficult for providers to offer nonjudgmental, sensitive counseling and care to victims if they share common misconceptions about violence and have negative attitudes toward victims. (7) In a survey of reproductive health care providers in the Dominican Republic, Peru, and Venezuela, for example, more than half of 79 respondents thought that some women's behavior was "inappropriate" and thus provoked their husbands' aggression. (8)

Some providers' own experience as victims or perpetrators of sexual coercion may affect their attitudes toward clients. In a study among South African public health nurses, 11 of 36 female nurses reported sexual abuse by an intimate partner, and six of eight male nurses admitted abusing a partner. Both male and female nurses thought violence against women was sometimes justified. (9)

Many providers are concerned about the effects of sexual coercion and other forms of violence. But they often report frustration that they cannot "fix" the problem and that some clients ignore their advice. (10) Trainers can help providers understand the difficulties abused clients face and the value of offering emotional support. (11)

Transforming systems

Lack of institutional support, community resources, referral networks, and evidence of effective interventions compromises providers' ability to help victims of sexual coercion or other forms of violence against women. (12) Providers are often expected to implement such services on their own after attending a single training session or workshop on sexual violence.

Many experts emphasize that effective service provision requires that policies and procedures for managing cases of sexual violence against women become standard practice throughout an entire health care system. (13) This "systems approach" requires attention to details of clinical infrastructure, such as ensuring that a facility has a cabinet with a lock for storing clients' records and a room where clients can be asked about violence without being overheard by partners, relatives, or other clients. (14) It also involves supporting staff through ongoing training and supervision and, perhaps, by designating a staff violence specialist or holding monthly meetings to discuss difficult cases and help providers cope with emotional stress. (15)

In one example of such a systems approach, the International Planned Parenthood Federation/Western Hemisphere Region (IPPF/WHR) and its member associations in the Dominican Republic, Peru, and Venezuela reviewed all aspects of their health programs before beginning to screen clients for experience with sexual coercion, sexual abuse in childhood, and violence within their families. Aspects that were evaluated included patient flow, clinic infrastructure, staff training, treatment protocols, clinical history forms, data systems, and agreements with referral organizations. The member associations even changed their hiring procedures to ask job candidates about their views on violence against women, seeking out people who shared the organizations' commitment to assist victims. (16)

Evidence needed

IPPF/WHR and its member associations in the Dominican Republic, Peru, and Venezuela were able to both identify cases of sexual, physical, or psychological abuse of women and offer comprehensive services in their clinics or through referrals. (17) Meanwhile, a growing number of other organizations are taking on the challenges of detecting, treating, and preventing sexual coercion and other forms of violence against women.

In Brazil, the number of public hospitals providing comprehensive care to women who experience sexual violence rose from just three in 1996 to 63 in 2001 through the advocacy and training efforts of obstetrical and gynecological societies. Screening clients for violence and then offering victims counseling and referrals is being tested in primary health care centers in Sao Paulo. (18) Another initiative by the USAID-funded PRIME II project raised awareness about physical, sexual, psychological, and economic abuse of women and the need for legal protection against such abuse. It also established screening, counseling, and referral services for abused clients in a busy reproductive health clinic in the Armenian capital of Yerevan. (19) In South Africa, an alliance of individuals and organizations is working with the government to change policies, raise community awareness, and improve health sector responses to sexual violence. (20) Program implementation there has lagged behind policy reform, (21) but guidelines for clinical management of victims of sexual assault have been developed, and the government plans to train service providers to use them.

Similar pilot programs are also under way in countries such as Bangladesh, Costa Rica, India, Nicaragua, the Philippines, and Venezuela. (22) Few efforts have been evaluated, however, and most evaluations that have been conducted have been limited to measuring detection rates or changes in provider attitudes or practices. Measuring the impact of provider intervention is difficult because of the need to rely on self-reported experiences of violence and ethical concerns about withholding services from members of study comparison groups.

Because limited evidence is available on how screening and other provider interventions affect clients' health or exposure to further violence (see article, page 17), experts have called for more rigorous evaluation of such interventions. This includes, in a variety of health care settings, randomized controlled trials and qualitative research among women who have experienced physical or sexual abuse to analyze which interventions they think are effective, and why. (23)

References

(1) Bott S, Guedes A, Guezmes A. The health service response to sexual coercion/violence: lessons from IPPF/WHR members associations in Latin America. Non-consensual Sexual Experiences of Young People in Developing Countries: A Consultative Meeting. New Delhi, India, September 22-25, 2003.

(2) Stevens L. A Practical Approach to Gender-based Violence: A Programme Guide for Health Care Providers and Managers. New York, NY: United Nations Population Fund, 2001; Watts C, Mayhew S. Reproductive health services and intimate partner violence: shaping a pragmatic response in sub-Saharan Africa. Int Fam Plann Perspect 2004; 30(4):207-13.

(3) Jejeebhoy S, Bott S. Non-consensual Sexual Experiences of Young People: A Review of the Evidence from Developing Countries. New Delhi, India: Population Council, 2003.

(4) Bott S, Guedes A, Claramunt MC, et al. Improving the Health Sector Response to Gender-based Violence: A Resource Manual for Health Care Professionals in Developing Countries. New York, NY: International Planned Parenthood Federation, Western Hemisphere Region, 2004.

(5) Garcia-Moreno C. Dilemmas and opportunities for an appropriate health-service response to violence against women. Lancet 2002;359(9316):1509-14; Waalen J, Goodwin MM, Spitz AM, et al. Screening for intimate partner violence by health care providers: a review of barriers and interventions. Am J Prev Med 2000;19(4):230-37; Guedes A, Stevens L, Helzner J. Addressing gender-based violence in a reproductive and sexual health program in Venezuela. In Haberland N, Measham D, eds. Responding to Cairo: Case Studies of Changing Practice in Reproductive Health and Family Planning. New York, NY: Population Council, 2002.

(6) Christofides N, Webster N, Jewkes R, et al. The State of Sexual Assault Services: Findings from a Situation Analysis of Services in South Africa. Pretoria, South Africa: South African Gender-based Violence and Health Initiative, 2003.

(7) Garcia-Moreno; Jejeebhoy.

(8) Guedes A, Bott S, Cuca Y. Integrating systematic screening for gender-based violence into sexual and reproductive health services: results of a baseline study by the International Planned Parenthood Federation, Western Hemisphere Region. Int J Gynaecol Obstet 2002;78(Suppl 1):57-63.

(9) Kim J, Motsei M. "Women enjoy punishment": attitudes and experiences of gender-based violence among PHC nurses in rural South Africa. Soc Sci Med 2002;54(8):1243-54.

(10) Garcia-Moreno; Guedes, Stevens, Helzner.

(11) Bott, Guedes, Claramunt.

(12) Garcia-Moreno.

(13) Heise L, Ellsberg M, Gottemoeller M. Ending violence against women. Popul Rep 1999;27(4):36.

(14) Garcia-Moreno; Stevens.

(15) Stevens; Parsons L, Goodwin MM, Petersen R. Violence against women and reproductive health: toward defining a role for reproductive health care services. Matern Child Health J 2000;4(2):135-40; Llorens M, Medina S. Support groups for providers. Basta! March 2002. Available: http://www. ippfwhr.org/publications/download/serial_issues/ basta200203_e.pdf.

(16) Bott, Guedes, Guezmes.

(17) Bott, Guedes, Guezmes.

(18) Faundes A, Andalft J. Sexual violence against women. The role of gynecology and obstetrics societies in Brazil. Int J Gynaecol Obstet 2002;78(Suppl 1):67-73; Schraiber LB, d'Oliveira AF. Violence against women and Brazilian health care policies: a proposal for integrated care in primary care services. Int J Gynaecol Obstet 2002;78(Suppl 1):21-25.

(19) Newman C, Sargsyan I, Kohler R, et al. Improving Primary Providers' Response to Violence Against Women in Reproductive Health Services in Armenia. Yerevan, Armenia: PRIME II Armenia, 2004.

(20) Christofides.

(21) Guedes A. Addressing Gender-based Violence from the Reproductive Health/HIV Sector: A Literature Review and Analysis. Washington, DC: Poptech, 2004.

(22) Haque YA, Clarke JM. The Woman Friendly Hospital Initiative in Bangladesh setting: standards for the care of women subject to violence. Int J Gynaecol Obstet 2002;78(Suppl 1):45-49; Stevens.

(23) Garcia-Moreno; Nelson HD, Nygren P, McInerney Y, et al. Screening women and elderly adults for family and intimate partner violence: A review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2004;140(5):387-96; Gazmararian JA, Petersen R, Spitz AM, et al. Violence and reproductive health: current knowledge and future research directions. Matern Child Health J 2000;4(2):79-84.