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The Center for Health and Gender Equity (CHANGE) is a research and advocacy organization that seeks to integrate concern for gender equity and social justice into international health policy and practice. CHANGE staff can be reached by e-mail at change@genderhealth.org or at http://www.genderhealth.org.

Lack of confidentiality can be particularly devastating, as well as placing women at risk for further abuse. A women in Zimbabwe complained, “I went to the hospital because my husband beat me when I got pregnant. What hurt me was that there was no confidentiality by the doctors and nurses treating me. Everyone in the ward got to know that I had been beaten by my husband” (465).

For many women, facing indifference and hostility from health personnel is like being victimized again by the very system that is supposed to help. One Latin American woman who went to a health center said, “I felt hurt, wounded, because when you go, you hope that someone would at least give you a little help. But when you get there you feel even more dejected.... They don't give you any encouragement.... They treat you like the cashier in the supermarket” (202).

A Panamanian woman who miscarried as a result of her husband's beatings described her experience with the health center in this way:

When the doctor attended me, I explained to him what happened, that I had been beaten, and I said, “I know this isn't your job, but I need a favor. My husband is outside in the hallway, and I need you to call a policeman to help me stop him before he catches me again.” The doctor answered that this wasn't his problem, that I was free to leave however I wanted. He just said, “Take this for the swelling” and left me alone in the room. (347)

“It is my impression that some women have been waiting their whole lives for someone to ask,” notes Ana Flavia d'Oliveria, a Brazilian public health physician who began an abuse screening program among her prenatal care patients (213). In fact, most women, regardless of whether they have been abused themselves, feel that physicians should routinely ask their patients about abuse (71, 161). Among South African women attending a community health clinic in Cape Town, for example, 88% said they would welcome routine inquiry about violence during health visits (251).

The way in which a woman is asked about violence makes an enormous difference to whether she will disclose her situation. If asked about violence in a nonjudgmental, empathic way, she is more likely to answer truthfully. Women are more inclined to discuss abuse if they perceive the clinician to be caring and easy to talk to, and if follow-up is offered (293, 379).

Placing brochures or posters about domestic violence in a clinic or office can increase women's comfort in talking about abuse (293). Sometimes, medical staffs have found it helpful to wear buttons with the message “It's OK to talk to me about family violence and abuse.” A US medical association produced a poster to place in waiting rooms saying, “We may forget to ask, but we always want to know if you are experiencing violence at home” (48).

Domestic Violence Center of Howard County, Maryland

Strategically placing posters or brochures around health clinics can encourage women to feel at ease in bringing up the topic of abuse. This US poster has a pocket to hold brochures.

Several short screening questionnaires have been developed to help health care providers identify victims of abuse (120, 146, 295). At one prenatal clinic, detection of lifetime violence rose from 14% with routine inquiry during a social service interview to 41% using the 5-question Abuse Assessment Screen (328). Another study found that asking three brief questions correctly identified the majority of abused women:

Cousins/Women and Law in Southern Africa (500)

When a woman discloses abuse, it is important that providers ask questions in ways that are sensitive and supportive, that do not tell women what to do but that help them examine their options. What providers say and counsel often influences their clients' attitudes and actions.

1. “Have you been hit, kicked, punched or otherwise hurt by someone within the last year? If so, by whom?”
2. “Do you feel safe in your current relationship?”
3. “Is there a partner from a previous relationship who is making you feel unsafe now?”

There is no international consensus on whether all women should be routinely screened for violence when they visit a health care facility. Some advocates argue that failure to screen is a serious breach in the quality of health care (49). Others feel that screening all women on every visit may not be feasible, particularly where budgets are low and personnel are overworked. Some express concern that identifying women who are abused may be counterproductive if there are no services or resources to offer them and could lead to greater frustration for both clients and providers (277).

Each health service should decide upon a detection policy that best meets its clients' needs and local resources. Options other than universal screening include:

Ask when there are signs of abuse. Without asking, it is difficult to identify women suffering abuse. Providers should keep in mind that, contrary to popular belief, physical injury is not the most common symptom of abuse in women. More common are chronic vague complaints with no obvious physical cause. Such complaints and other key symptoms raise “red flags” about domestic violence and sexual abuse that should arouse providers' suspicions (166, 343, 370) (see How to Ask About Abuse of the Pullout Guide). When one or more of these symptoms are present, health workers should ask directly about abuse.

Strategic screening. Another option is to screen all women for abuse in certain services that are considered strategic because of the number of abused women attending them, because special risks are involved, or because they present good opportunities for discussing abuse. Routine screening might be especially appropriate in the following services:

• Maternal and child health services. Because violence is at least as common and often more serious than a variety of other conditions that health workers routinely screen for during pregnancy, most experts contend that all women attending prenatal care should be screened for abuse (64, 295). The prenatal care setting is especially conducive to discussing abuse because trust can develop as women return for repeat visits. Postpartum screening is also important, since violence may become more frequent or more severe after delivery (176). Pediatric and well-baby visits provide another good opportunity to identify and provide support for mothers and children living with violence (20).
• Reproductive health services. Discussions about contraception or STI prevention provide a good opportunity for discussing abuse. Women who have been abused in the past or who currently suffer violence may be unable to control the timing of sexual encounters or to negotiate condom use. Therefore routine screening in family planning and STI prevention programs is essential to ensure that counseling messages are tailored to the needs of battered and sexually or emotionally abused women.
• Mental health services. Because violence is associated with such mental health disorders as depression and post-traumatic stress disorder (53, 66, 375), women attending mental health services should be considered a particularly high-risk group for violence.
• Emergency departments. Partner violence is a cause of many physical injuries among adult women (see Chapter 5.2), and women with injuries that warrant emergency medical attention are likely to be among those most severely abused. Therefore, a reasonable policy is to ask all women coming to emergency rooms with traumatic injury whether their injuries are due to intimate partner violence (120, 297).