Health care providers can help solve the problem of violence against women if they learn how to ask clients about violence, become better aware of signs that can identify victims of domestic violence or sexual abuse, and help women protect themselves by developing a personal safety plan. Everyone can do something to help promote nonviolent relationships.

Health Care Workers, Are We Part of the Problem?

Women’s advocates in the US have used the “power and control” framework for many years to describe how some men use violence to dominate their partners and maintain control with the relationship. The wheel at right is adapted from that framework to show how the behavior of health care providers often contributes to women’s victimization.

	Or Are We Part of the Solution?
An alternative wheel suggests how health workers can help empower women to overcome abuse.*
*Adapted from: The Medical Power & Control Wheel. Developed by the Domestic Violence Project, Inc., 6308 Eighth Ave., Kenosha, WI 53143, USA.

This guide was prepared by the Center for Health and Gender Equity for Population Reports, Ending Violence Against Women, Series L, No. 11, December 1999.

How to Ask About Abuse
One day after reading an educational booklet on domestic violence, Richard Jones, former president of the American College of Gynecologists and Obstetricians, asked a long-time patient whether her husband had ever beaten her. To his amazement, she replied, “Doctor Jones, you can’t imagine how long I’ve been waiting for you to ask me that question” (242).

Any service provider can make a difference by “asking the question.” Jones now asks every patient about abuse and encourages all of his students to do likewise. An important first step is considering how to broach the subject and then developing a standard way to ask the question for all clients. Here are some options:

Introducing the Question "Before we discuss contraceptive choices, it might be good to know a bit more about your relationship with your partner.” “Because violence is common in women’s lives, we have begun asking all clients about abuse.” “I don’t know if this is a problem for you, but many of the women I see as clients are dealing with tensions at home. Some are too afraid or uncomfortable to bring it up themselves, so I’ve started asking about it routinely.” Asking Indirectly “Your symptoms may be related to stress. Do you and your partner tend to fight a lot? Have you ever gotten hurt?” “Does your husband have any problems with alcohol, drugs, or gambling? How does it affect his behavior with you and the children?” “When considering which method of contraception is best for you, an important factor is whether you can or cannot anticipate when you will have sex. Do you generally feel you can control when you have sex? Are there times when your partner may force you unexpectedly?” “Does your partner ever want sex when you do not? What happens in such situations?” Asking Directly “As you may know, it’s not uncommon these days for a person to have been emotionally, physically, or sexually victimized at some time in their life, and this can affect their health many years later. Has this ever happened to you?” “Sometimes when I see an injury like yours, it’s because somebody hit them. Did that happen to you?” “Has your partner or ex-partner ever hit you or physically hurt you?” “Has your partner ever forced you to have sex when you didn’t want to?” “Did you ever have any upsetting sexual experiences as a child?” Questions for Use in Clinical Histories or Patient Intake Forms “Are you currently or have you ever been in a relationship where you were physically hurt, threatened, or made to feel afraid?” “Have you ever been raped or forced to engage in sexual activity against your will?” “Did you ever have any unwanted sexual experiences as a child?”

When providers ask about violence, women will have many things to tell them. Suggestion: Discuss with colleagues how to respond with empathy and respect. Sources: Center for Health and Gender Equity and Family Violence Prevention Fund, 1988 (460).

Domestic Violence		Sexual Abuse
	Chronic, vague complaints that have no obvious physical cause,		Pregnancy of unmarried girls under age 14,
	Injuries that do not match the explanation of how they occurred,		Sexually transmitted infections in children or young girls,
	A male partner who is overly attentive, controlling, or unwilling to leave the woman’s side,		Vaginal itching or bleeding,
	Physical injury during pregnancy,		Painful defecation or painful urination,
	Late entry into prenatal care,		Abdominal or pelvic pain,
	A history of attempted suicide or suicidal thoughts,		Sexual problems, lack of pleasure,
	Delays between injuries and seeking treatment,		Vaginismus (spasms of the muscles around the opening of the vagina),
	Urinary tract infection,		Sleeping problems,
	Chronic irritable bowel syndrome,		A history of chronic, unexplained physical symptoms,
	Chronic pelvic pain.		Having difficulty with or avoiding pelvic exams,
			Problems with alcohol and drugs,
			Sexual “acting out,”
			Extreme obesity.
Fuente: Center for Health and Gender Equity y Family Violence Prevention Fund (460).

Health care providers can help women protect themselves from domestic violence, even if the women may not be ready to leave home or report abusive partners to authorities. When clients have a personal safety plan, they are better able to deal with violent situations. Providers can review these points and help each woman develop her own personal safety plan:

	Identify one or more neighbors you can tell about the violence, and ask them to seek help if they hear a disturbance in your home.
	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 might be available.
	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 own 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.
	Decide where you will go if you have to leave home and have a plan to get there (even if you do not think you will need to leave).
	Use your instincts and judgment. If the situation is dangerous, consider giving the abuser what he is demanding to calm him down. You have the right to protect yourself and your children.
	Remember: you do not deserve to be hit or threatened.

How to Promote Nonviolent Relationships Wherever You Are
Everyone can do something to promote nonviolent relationships.

Health workers can:

	Educate themselves about physical, sexual, and emotional abuse and explore their own biases, fears, and prejudices.
	Provide supportive, nonjudgmental care to victims of violence.
	Ask clients about abuse in a friendly, gentle way.

Leaders of reproductive health programs can:

	Establish policies and procedures to ask women clients about abuse.
	Establish protocols that clearly indicate appropriate care and referral for victims of abuse.
	Promote access to emergency contraception.
	Lend facilities to women’s groups seeking to organize support groups and to hold meetings.

Community and religious leaders can:

	Urge understanding, compassion, and concern for victims of violence.
	Challenge religious interpretations that justify violence and abuse of women.
	Make their houses of worship available as temporary sanctuary for women in crisis.
	Provide emotional and spiritual guidance to victims of abuse.
	Support the efforts of abused women to leave relationships that put them at risk.
	Integrate discussions on healthy relationships and alternatives to violence into religious education programs.

The mass media can:

	Respect the privacy of victims of rape by not printing their names without their permission.
	Avoid sensationalizing cases of violence against women; place events in their proper context, and use them as an opportunity to inform and educate.
	Provide free airtime or space for messages about gender violence and announcements of available services.
	Reduce the amount of violence portrayed on television.
	Develop socially responsible radio and television programming that depicts equitable and nonviolent relationships between men and women.
	Develop programming that creates public dialogue about sexual coercion, rape, and abuse.

Parents can:

	Refrain from arguing in front of their children.
	Teach their children to respect others and themselves.
	Encourage the health, safety, and intellectual development of their daughters as well as their sons, and encourage their self-esteem.
	Avoid hitting their children; use nonviolent forms of discipline instead.
	Teach children nonviolent ways to resolve conflicts.
	Talk to their children about sex, love, and interpersonal relationships; emphasize that sex should always be consensual.

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