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A complex interplay of professional, cultural, personal, and institutional concerns shape the ability and willingness of health workers to address domestic violence, according to studies in Africa, Asia, Latin America, and the US (86, 143, 252, 361, 374, 428, 465). Some of the biggest barriers that block effective response are health care providers' lack of technical competence, cultural stereotypes and negative social attitudes, and institutional constraints.

Lack of technical competence and resources. Health workers often do not ask women about their experience with violence because they feel unprepared to respond to the needs of victims. Some view domestic violence as a private issue and fear that clients would be upset or offended if asked about violence. Others feel that they do not have the time or resources to help (86, 374, 428).

Practitioners who have received special training on violence are more likely to inquire about violence and to feel competent to address the needs of abused women (309, 434). Although some professional schools are making efforts to address domestic violence—for example, nursing schools in the US (476)—most professional schools worldwide do not addressviolence or do so only minimally (5, 321, 353). For example, a study in the US found that two-thirds of health practitioners had never received training on domestic violence (434). In Mexico and Zimbabwe health care providers said that their medical training was in fact an obstacle to dealing with abuse because it prepared them only to address a patient's physical symptoms rather than the whole person (143, 465).

Cultural stereotypes and negative social attitudes. Health care providers typically share the same cultural values and societal attitudes toward abuse that are dominant in the society at large. Thus they may think that some women deserve abuse or that a wife's obligation is to be sexually available to her husband at all times (252). They also frequently assume that domestic violence and sexual assault occur only among poor women or among women of certain ethnic or religious backgrounds (86, 252). Such attitudes stand in the way of sympathetic and caring response to abused women who seek care.

For example, in South Africa a study found that female nurses generally recognized domestic violence as a serious problem for women but also thought that women themselves held attitudes and acted in ways that could provoke violence, including rape (252). Male nurses reported a long list of reasons that would justify a man in beating his wife, including if she disobeyed him, was disrespectful, or neglected household or childcare duties. They did not think that a man had committed rape if he forced his wife to have sex, and they thought that the practice of wife-beating was both a means of discipline and a way of expressing love or forgiveness (252).

Even in cultures where partner violence is considered unacceptable, negative social attitudes about battered women are often deeply imbedded and difficult to overcome. These beliefs may affect how health workers assess a woman's truthfulness or her responsibility for her situation. In the US, for example, clinicians revealed their biased attitudes by making such statements as “A battered woman tells you what you want to hear” and “Women in violent situations are difficult to deal with. We find it hard to accept women who don't get out of such a situation” (86).

Some male clinicians may hesitate to accept a woman's account of violence because they identify with the offender. As one US doctor said, “Maybe my discomfort with it is that I've experienced that kind of rage myself” (374). Female health workers who have themselves been victims of abuse also may have a hard time discussing violence with their clients. Studies have found that as many as one female health practitioner in every three has experienced violence herself (252, 309, 370, 428).

Institutional constraints. Clinicians working with victims of violence often feel that their institutions and colleagues value their work less than other types of clinical intervention (86). Most programs designed to address abuse in health care settings have been the work of very committed individuals, but their initiatives rarely have become institutional policy. With the departure of these key leaders, many programs lose momentum, and some end (86, 298).

Legal liability or involvement is a major concern that keeps health workers from doing more for victims of abuse. In some countries health workers often refuse to examine raped or otherwise abused women because they want to avoid having to testify in court (221, 347, 465). Other countries have passed laws mandating that health care providers report child abuse and, sometimes, abuse of adult women. With adult victims, however, such laws are generally counterproductive because they take control away from the abused woman, jeopardize her safety, and may make it less likely that she will seek health care for fear that her partner will be arrested as a result (7, 78, 221, 236, 461).

Sando Moore/Women's Rights International

Community leaders' commitment is key. Playing roles in the story of a woman raped in wartime, traditional birth attendants in Liberia learn to lead community response to sexual abuse of women.

The lack of referral services and insufficient coordination between health workers and referral services often prevent women from receiving necessary medical care, including emergency contraception and STI screening. In Zimbabwe a woman who had been raped reported that, “The police said they could not file my case without a medico-legal exam. I went to the matron (at the health center). I was then advised to come to the (women's center). They sent me to Social Welfare. At Social Welfare I kept on being referred from one person to another the whole day. I went back the next day and was told to go back to the police station” (465).

Women's reluctance to disclose violence. Unless women are asked directly about violence, many do not volunteer information. For example, as noted in Table 3, the 1998 Nicaragua DHS found that over one-third of women who had been abused by their partners had never told anyone. Although 57% of the women had suffered injuries, only 13% had ever received medical attention. Even then, most women did not disclose the cause of their injuries. Only 7% of women reported having ever sought help at a health center or hospital for violence (386).

Shame was one of the main reasons that women in Nicaragua gave for not disclosing violence. As one woman explained, “I thought that there were only a few people who lived like this and that it would be embarrassing for someone to find out that he was hurting me this way” (131). Many women say nothing about violence because they fear that they will be blamed for it. A US woman told researchers that, even though her injuries often brought her to the doctor, she had kept their cause to herself for nine years (379).

Fear of reprisals from their abusers is another reason that many women stay silent. As one woman in the US observed, “I knew that if I was to tell them what actually happened, they would call the police and I would have to file a report, and they couldn't guarantee me that they would be there 24 hours to protect me from this maniac” (379).

In much of the world women are unable to obtain health care without the knowledge or permission of their spouses or other male family members (333, 386). Women living in abusive relationships typically are subject to strict controls over their mobility, and abusive husbands may go to great lengths to keep them from getting help. Often, men will not allow their wives to visit a health center unescorted, especially if they are going to be treated for injuries due to violence (293). Women are especially unlikely to disclose abuse to a health care provider in front of their abuser.