Dr.

Cynthia Pitter

VIOLENCE
AGAINST WOMEN
AND GIRLS
WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023
 Pre-service curriculum at UWI

Overview Nursing and MBBS students. WHO/UWIFMS/UN

Module 1 VAWG as Public Health Issue- Concepts in

Year 2 Nursing

Module 2: First Line Support -Community Health Nursing

Module 4: Clinical Support for Mental Health- Mental Health
Year 3 Nursing
Module 5: Family Planning, HIV and Documentation-Parent Child
Nursing

Module 3: Care after Sexual Assault- Specialized Nursing/Senior

Year 4 Clinical Practicum
 OBJECTIVES
Session content

On completion of this Module, attendees should :

1. Know how to document VAW, specifically intimate
partner violence, in a safe and confidential manner
2. Demonstrate skills in identifying and caring for women
experiencing violence who present to either family
planning or HIV services.
• Conduct HIV risk related counselling
• Provide family planning counselling
• Documenting health information confidentially

WITHIN THE CONTEXT OF VIOLENCE AGAINST WOMEN & GIRLS

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023
 DEFINITION OF TERMS

Gender-based violence
• refers to harmful acts directed at an individual or a group of
individuals based on their gender.
• It is rooted in gender inequality, the abuse of power and harmful
norms.
• The term is primarily used to underscore the fact that structural,
gender-based power differentials place women and girls at risk
for multiple forms of violence.
• While women and girls suffer disproportionately from GBV, men
and boys can also be targeted.

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 VIOLENCE AGAINST WOMEN
& GIRLS
Violence against women and girls (VAWG)
• is defined as any act of GBV that results in, or is likely to
result in, physical, sexual or mental harm or suffering to
women and girls, including threats of such acts, coercion
or arbitrary deprivation of liberty, whether occurring in
public or in private life.
• VAWG encompasses, physical, sexual and psychological
violence and financial occurring in the family or within the
general community

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 SURVIVOR OF VIOLENCE

• refers to any person who has experienced

sexual or gender-based violence. It is similar
in meaning to “victim”, but is generally
preferred because it implies resilience
• It gives the person a sense of power (take
back the power).

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 OVERVIEW

• Violence against women and girls (Intimate

Partner Violence (IPV)or Domestic Violence) is
a serious public health issue and has been
linked to a range of adverse health outcomes.
• The prevalence of VAWG is link to HIV
transmission and the unmet need for family
planning among women of childbearing age

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 OVERVIEW
• A variety of social, cultural, and economic factors
could influence women’s decisions and autonomy
regarding family planning and contraceptive use
• Unmet need for family planning is defined as the
lack of use of any contraception method among
fecund and sexually active women who report not
wanting any more children or wanting to delay the
next child
• It is likely that women experiencing IPV use and
seek less contraception out of fear of additional
violence from their partners.

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 OVERVIEW
• They may also be more vulnerable due to their
inability in negotiating their reproductive needs and
rights with their partners compared to other
women.
• On the other hand, women who experienced IPV
may be more willing to use contraception to avoid
pregnancy and born a child into abusive marriages
or relationships.
• In addition, to protect themselves from contracting
STDs and HIV/AIDs from a risky partner, they may
also prefer and seek using contraceptives .

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 OVERVIEW
• The healthcare community plays an important role
in screening, treating, and documenting domestic
violence. A healthcare facility may be the first and
only setting for disclosures of domestic violence in a
safe forum.

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 SCENARIO 1
• Rita, a 20-year-old student, has come to you as a health worker
because she wants to take an HIV test. She says her boyfriend
sent her to take the test because he says he does not trust her.
Rita says that she is worried about taking the test because,
although she is faithful, she is afraid the test may be positive.
• Her boyfriend has cheated on her even though he denies this. He
becomes very angry if she talks about it. She looks very afraid and
nervous, and when you try to take the blood she pulls away.
When you finally do the test, the results come back positive. She is
devastated and does not want to talk about the results. She is
afraid of what people, especially her boyfriend, will say.

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 ADDRESSING SAFETY IN HIV
STATUS DISCLOSURE
In General,

 All women (including those in IPV situations) can benefit

from thinking through their disclosure of HIV testing and test
results.

 Healthcare providers can ascertain if a woman needs a

plan for safer disclosure of test results, or whether to disclose.

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023
 Direct and Indirect Pathways of HIV
Transmission linked to VAW

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 WHAT ARE SOME QUESTIONS WE
COULD ASK TO INITIATE A
CONVERSATION ABOUT IPV?
1. Has your partner ever hidden or taken away contraceptive pills
from you?

2. Have you ever been forced or pressured to get pregnant?

3. Has your partner ever forced you to have sex without a

condom?

4. Has your partner ever forced you to have sex without

contraceptive to get you pregnant?

5. Has your partner ever forced you to have sex when you said no?

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 FAMILY PLANNING
• Women who experience violence often seek health
services, although many will not mention the violence.
• Violence can lead to a range of health problems,
including injuries, unwanted pregnancy, sexually
transmitted infections (STIs) including HIV, decreased
sexual desire, pain during sex, and chronic pelvic pain.
• Violence may start or become worse during a
pregnancy, placing the fetus at risk as well. A man’s
violence or the threat of violence can deprive a
woman of her right to make her own choice about
whether to use family planning or what method to use.

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 FAMILY PLANNING
• Mary is 27 years old and comes to a health worker as she does not want

to get pregnant. She has two children, and her youngest is just 1 year

old. Five months ago she started taking the pill because she had come

in stating that she did not like condoms and wanted to use something

different. Mary has now come back and says she absolutely wants

something different again, because she does not like the pill. She does

not say why, but she really does not want to use the pill and insists on

preventing pregnancy another way.

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 Case Reviews
Instruction to participants:
Read the scenario and answer the following questions in your
capacity as a healthcare provider
1) Do you think the patient has experienced violence?

2) If so, how would you ask her about such experiences?

3) How would you discuss family planning with the patient? (if relevant to scenario) Remember
her safety is paramount.

4) How would you discuss your patient disclosing to her partner what her HIV status is? (if
relevant to scenario) Remember her safety is paramount.

3/2/2023 WHO/UWI FMS/UN Spotlight Initiative Jamaica

 HOW CAN FAMILY PLANNING
PROVIDERS HELP?
Family Planning Providers (FPP) can:

 Learn signs of IPV and initiation dialogue regarding violence

and/or reproductive coercion.

 Offer support using the LIVES strategy

 Counsel women about contraceptive choices based on their

safety concerns.

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 ADDRESSING SAFETY IN HIV
STATUS DISCLOSURE
In General,

 All women (including those in IPV situations) can benefit from

thinking through their disclosure of HIV testing and test results.

 Healthcare providers can ascertain if a woman needs a plan

for safer disclosure of test results, or whether to disclose.

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 WHAT ARE SOME QUESTIONS WE
COULD ASK TO INITIATE A
CONVERSATION ABOUT IPV?
1. Has your partner ever hidden or taken away contraceptive
pills from you?

2. Have you ever been forced or pressured to get pregnant?

3. Has your partner ever forced you to have sex without a

condom?

4. Has your partner ever forced you to have sex without

contraceptive to get you pregnant?

5. Has your partner ever forced you to have sex when you
said no?
WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023
 FAMILY PLANNING
• Help women feel welcome, safe, and free to talk.
• If you suspect violence, ask about it
•To increase trust, explain why you are asking—
because you want to help.
•Use language that is comfortable for you and best
fits your own style.
•Do not ask such questions when a woman’s partner
or anyone else is present or when privacy cannot be
ensured

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 FAMILY PLANNING
• “Many women experience problems with their husband
or partner or someone else they live with.”
• – “I have seen women with problems like yours who
have been having trouble at home.”
• You can follow it up with more direct questions, such as
these:
• – “Are you afraid of your husband (or partner)?”
• – “Has your husband (or partner) or someone else at
home ever threatened to hurt you or physically harm
you in some way? If so, when has this happened?”

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 FAMILY PLANNING
• Offer first-line support. • Listen
• LIVES • Inquire about needs and concerns
• Validate
• Enhance safety
• Support

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 FAMILY PLANNING
• Provide appropriate care.
• Tailor your care and counseling to a woman’s
circumstances.
• Treat any injuries or see that she gets treatment.
• Discuss with her how she can make the best
choices for family planning in her
circumstances.
• Document the abuse experienced by the woman.
• Carefully and confidentially document the
woman’s history of abuse along with symptoms
or injuries and the cause of the injuries if
relevant. Record the relationship of the
perpetrator to the woman.
WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023
 FAMILY PLANNING

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 Why is documentation of Intimate Partner
Violence (IPV) important?

Documentation is important as it…

• provides sensitive care to patients
• reminds any attending healthcare provider of the
patient’s status at later visits
• documents injuries which can be used IF the patient
decides to report the violence to the police

3/2/2023 WHO/UWI FMS/UN Spotlight Initiative Jamaica

 Institutions’ Confidentiality Practices
Based on your awareness (i.e., experience and training):
• What steps do healthcare settings take to ensure confidentiality of patients’ records? Do you
know of anything specific for VAW?
• What procedures should a provider follow if a patient confides to them about an incident of
VAW?
• What, if any, are the reporting requirements if a provider is informed about VAW? If minors are
affected by that incident of VAW?
• Where and how are medical records and documents filled out and stored, and how is
confidentiality ensured in this process?
• Who has access to patients’ records?
• Could a perpetrator gain access to medical records in any form (i.e., docket, online patient portals)?

• Can anyone else get patients’ personal and/or identifiable information to share with others?
3/2/2023 WHO/UWI FMS/UN Spotlight Initiative Jamaica
Confidentiality in Documentation: Best Practices for Maintaining
Confidentiality of Patients’ Reports of Violent Incidents

What are good confidentiality practices when documenting patients’

reports?
1. Explain to the patient what you need to write down & why
2. Follow her wishes if she does not want something to be written down
3. Do not ask about violence in a public place
4. Do not document violence in a public place
5. Do not write any indication of violence on…
1. cover or first page of patient record
2. other records that might be seen by those who don’t need to know (for
example, bed charts, X-ray slips)
3. any record that the woman might take home
3/2/2023 WHO/UWI FMS/UN Spotlight Initiative Jamaica …continued…
Confidentiality in Documentation: Best Practices for Maintaining
Confidentiality…continued

6. If you must report to the authorities (e.g., minors involved), explain to the
patient the limitations on confidentiality
7. Make sure documents are not left out where others can see
8. Ensure that documents are locked up when not in use
9. Share documentation and information only with those who need to know

These practices must be performed within the standard operating

procedures of the specific healthcare setting.

3/2/2023 WHO/UWI FMS/UN Spotlight Initiative Jamaica

 HOW TO DOCUMENT PATIENTS’ ACCOUNTS OF VIOLENT INCIDENTS

1. Note location on body of any directly observed or reported

injury. Take pictures if possible.
2. Write legibly
3. Indicate in the records, if possible, how much time has
elapsed since the violent incident occurred, e.g., Patient
states that early this morning her husband chopped her.
4. Use patients’ own words as much as possible using
quotation marks, e.g., patient states she was “kicked in my
stomach”, patient reports “hair was pulled out of my
head”.
5. Describe the person who hurt the patient using quotation
marks, e.g., The patient stated, “My boyfriend punched
me.”

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 HOW TO DOCUMENT…CONTINUED
6. Do not use language which questions patients’ reliability
(e.g., patient claims, patient alleges). If your observations
contradicts patient’s statements, record the reason(s) for
this difference.
7. Avoid legal terms; only use medical terms. So, do not use
terms like “domestic violence” or abbreviations such as
“DV” in the diagnosis section of the medical record – they
are not medical terminology.
8. Describe the patient’s demeanour in the records, e.g., she is
crying, shaking, seems angry, calm, agitated, even if her
demeanour belies the evidence of abuse.

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 DOCUMENTATION
• Objectively document any injuries suggesting domestic
violence. With the patient's permission, take
photographs: using an injury location chart or body
map
• Use quotation marks to denote the patient's own words
• Avoid legalese. Document in a factually neutral
manner, avoiding phrases or words such
as alleges, which have specific legal meanings.
• Identify the person who hurt the patient as stated by the
patient, using quotation marks and recording the
identifying information

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 DOCUMENTATION
• Don't write your personal conclusions about the
situation, such as patient is a battered woman
• Don't put the term domestic violence or abbreviations
such as "DV" in the diagnosis fields of a patient's
medical records. It's up to the courts to determine
whether domestic violence has occurred
• Record your observations of the patient's general
appearance or demeanor.2 For example, Patient crying
and seems agitated.
• Record the time of day the patient is examined.

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 DOCUMENTATION

• Write legibly or use a computer to document the

patient's medical information.
• Following facility policy and procedure and state
law, report any disclosure from your patient of child
or elder abuse to local authorities

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 TITLE LOREM IPSUM DOLOR

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023

 • The end

WHO/UWI FMS/UN Spotlight Initiative Jamaica 3/2/2023