Primary Health Care Gender-Based Violence Training

Module 3: Identifying and Assessing GBV Survivors

In this module, you will learn about signs and symptoms of violence and how to provide a safe, confidential environment for providing care to GBV survivors.

Learning Objectives

By the end of this module, you will be able to:

  • Identify signs, conditions, and symptoms that suggest that a GBV assessment be conducted.
  • Establish basic safety for conducting a GBV assessment.
  • Identify ways to ensure confidentiality and patient privacy.
  • Explain confidentiality to patients.
  • Ask questions of patients to learn key details of GBV exposure (timing, relationship to perpetrator/s, severity, number of occurrences, etc.).
  • Explain the key parts of history taking.

Learning Activities

  • Reading: Andiswa’s Story (5 min)

    Andiswa, a 26-year-old woman, is at your clinic with a broken wrist. Her friend, Thuli, is with her. You have seen Andiswa previously for gastrointestinal symptoms. However, you have not yet been able to determine a cause for her GI symptoms. In previous visits, she has been treated for chlamydia and shown symptoms of depression. She has told you that she has trouble sleeping. You suspect that someone might be abusing her. You are very concerned about her and want to find out if your suspicions are correct.

    Take a moment to consider: Why do Andiswa’s complaints suggest abuse (remember, this might be emotional abuse)? How will you proceed with caring for Andiswa?

    In this module, you will learn about how to identify signs and symptoms of violence. You will also learn to establish a safe, confidential environment for providing care to patients like Andiswa. Finally, you will have a chance to apply the communication skills you learned in Module 2 to a situation like Andiswa’s.

  • Reading: Identifying Signs & Conditions (5 min)

    Physical, emotional, and sexual abuse may cause or make worse a person’s health problems. People who experience abuse may come to a health facility for related emotional or physical conditions, including:

    • Symptoms of depression, anxiety, PTSD, sleep disorders
    • Suicidality or self-harm
    • Alcohol and other substance use
    • Chronic pain (unexplained)
    • Unexplained chronic gastrointestinal symptoms
    • Unexplained headaches or migraines
    • Unexplained genitourinary symptoms, including frequent bladder or kidney infections or other
    • Adverse reproductive outcomes, including multiple unintended pregnancies and/or terminations, delayed pregnancy care, adverse birth outcomes
    • Unexplained reproductive symptoms, including pelvic pain, sexual dysfunction
    • Repeated vaginal bleeding and sexually transmitted infections (STIs)
    • Traumatic injury, particularly if repeated and with vague or implausible explanations
    • Problems with the central nervous system: headaches, cognitive problems, hearing loss
    • Repeated health consultations with no clear diagnosis
    • Intrusive partner or husband in consultations
    • Absent for her own or her children’s health-care appointments
    • Emotional and behavioural problems in children

    A patient may not share with you the causes for these conditions because they may be afraid of the perpetrator or of being judged. Any patient may have experienced violence, whether they are a woman or a man, old or young.

    Note: The World Health Organization does not recommend universal screening for violence of women attending health care, but encourages providers to bring up the topic with patients with injuries or conditions that could be from violence.

    All survivors are different, and all clinics have a different capacity to support survivors. It is important to know what you can and cannot do for a survivor of sexual assault at your facility and in your role. When providing care for survivors, it is essential that you are not judgmental. The wishes of the survivor will determine what kind of care you provide.

    Click or tap each tab below to see what kind of key assurance to give a survivor when shares her account of GBV.

    You believe them

    When a survivor is disclosing their story to you, be sure to acknowledge their feelings by nodding your head or saying, ‘I understand.’

    They are safe

    Assure them that they are in a safe environment, and that anything they tell you will be kept confidential.

    They have your respect

    Be sure to show that you respect their dignity and do not express negative judgments about them or others.

  • Reading: Establishing a Safe Environment for Care (10 min)

    A person who comes to the clinic for help following an incident of violence has just experienced a trauma and a situation in which they were unsafe. Therefore, when seeking help, they need to feel safe. If a person is made to feel unsafe during the process of seeking help, there is a chance they will be re-traumatised.

    Some of the ways to make a survivor feel safe are the same as the ways you might make them feel respected and protect their privacy.

    Click or tap on each tab to find out what to do and not do to make a survivor feel safe at the clinic.

    Do
    • Establish eye contact as appropriate for the cultural setting
    • Establish privacy as soon as possible, as the survivor may be disoriented
    • Try to reduce time spent waiting when possible
    • Provide a quiet, private place to conduct any interview and examination
    • Demonstrate a nonjudgmental attitude
    • Explain every step of what you are doing and why you are doing it
    Do not
    • Confront a suspected abuser or accomplice who may be present with the survivor
    • Ask questions in front of the suspected abuser/perpetrator
    • Ask questions with anyone else present, so that the survivor can respond as freely as possible

    For Child Survivors

    For child survivors, be sure to:

    • Offer to have a trusted adult present when you talk to the child, but do not insist. This will depend from the child’s age. For adolescents, ask their permission when you are alone with them. If you ask in front of their parents, they might agree just to please the parents.
    • Use simple and clear language, appropriate to the child’s developmental stage, when giving information and asking questions.
    • Not allow the person suspected of abusing the child to be present during the interview or exam.
    • Tell the child the truth, even if it makes you uncomfortable.
    • Explain why you are talking with the child and what is happening at every step.
    • Pay attention to the child’s non-verbal communication.
    • Respect the child’s opinions and feelings, just as you would an adult.
    Sex of the Care Provider

    In many cases, it will not be possible to choose the sex of the care provider. Where possible use a provider of a different sex from the perpetrator. If this isn’t possible, when touching the survivor let them know that the touch is to provide medical care, not to abuse.

    For children use a provider of the same sex for girls, unless the perpetrator was the same sex, in which case, give a choice of male or female. Give boys the choice between a male or female provider.

  • Reading: Maintaining Privacy & Confidentiality (5 min)

    Maintaining privacy and confidentiality will avoid putting a survivor of GBV at risk of further harm. Click or tap on each term to learn more about it.

    Privacy

    Privacy means making sure that survivors maintain the right to control what information is collected about them, how it is used, who uses it, who maintains it, and what purpose it is used for.

    To ensure privacy with GBV survivors, be sure that it is just the two of you when discussing the situation. No one older than age two should overhear your conversation. It is not appropriate to talk about what happened if a spouse, partner, other family members, or anyone else who has accompanied the survivor is present or can overhear. If the survivor is accompanied by another person, you can send that person to do an errand, such as filling out a form, so that you can see the survivor alone. If children are with a survivor, ask a colleague to look after them while you talk.

    Confidentiality

    Confidentiality means that information (such as health records) is protected against unintended or unauthorized access. To maintain confidentiality of GBV survivors, keep their health records and any other documentation in a safe place, not out on a desk or anywhere else that anyone can see them.

    If the survivor must take paperwork with her or him (for the police, for example), discuss what she or he will do with the paper to keep the information confidential. In the next module we will discuss history-taking in more depth.


    Reporting to the Police

    In South Africa, it is mandatory (required) for healthcare providers to report any sexual assault of a child (person under 18 years of age) to the police. Healthcare providers are not required to report the assault of an adult, as that is the survivor’s decision; however the South African legal framework dictates that healthcare providers must report abuse of children, whether it is suspected or reported.

    Be clear about the law when speaking to a minor or their advocate. Healthcare providers are responsible for reporting even when the minor is accompanied by another person. If you must report violence to the police legally, you must inform the survivor. You can say, for example, “What you tell me is confidential, that means I will not tell anyone else about what you share with me. The only exception to this is..." Assure the survivor that, outside of this required reporting, you will not tell anyone else without her permission.

    Ensuring Privacy and Maintaining Confidentiality

    Things you can do to ensure privacy and maintain confidentiality:

    • Establish a separate room, if possible, or screened off area to consult with the survivor where you will not be seen or overheard.
    • Wait to ask sensitive questions—even the question “What happened”—until you have the patient in a private area of the clinic.
    • Stress the importance of being truthful and of the value of her/his account.
    • Do not share survivor information with any friends, family members, or the persons accompanying the survivor without the survivor’s permission.
    • Share survivor information with other clinic staff on a strictly “need to know” basis.
    • Keep any records, forms, notes, or other documentation in a safe place.
    • Talk with the survivor about what to do with any papers they will take with them.
    • Be clear with the survivor about any legal requirements for you to share information (for example, with the police).
  • Reading: Introducing the Subject of Violence (5 min)

    Recall the story of Andiswa from the beginning of this module. You suspect that she might be a survivor of intimate partner violence because of her past history of unexplained gastrointestinal issues, depression, and trouble sleeping. At today’s visit for her broken wrist, she has brought her friend, Thuli, with her.

    Should you:

    Introducing the Topic

    Click or tap on each number to read about how you should introduce the topic of violence.

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    Wait until the patient is alone to bring up the topic.

    Before asking the patient questions specifically about violence, first put her at ease by asking more neutral questions. Such questions could include asking who she lives with or what her duties are at home.

    Raise the topic of violence by asking questions unrelated to her particular experience to determine whether she is receptive to talking about it. Some statements you can make to introduce this topic include:

    • “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 experiencing trouble at home.”

    Once she has indicated that she is willing to discuss her experience, you can then ask her some closed-ended questions. (To review open- and closed-ended questions, go back to Module 2: Communication Skills.) You can preface this by telling her “I would like to ask you a few personal questions, is that okay?” If she consents, let her know that she can answer or simply nod her head yes or no. You should let her know that she does not have to answer any question she does not feel comfortable answering.

    Questions to Ask

    Here are some questions to ask a survivor:

    • “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 yes: “How often does this happen?”
    • “Does your husband (or partner) or someone at home bully you or insult you?" If yes: “How often does this happen?”
    • “Does your husband (or partner) try to control you, for example not letting you have money or go out of the house?” If yes: “How often does this happen?”
    • “Has your husband (or partner) forced you into sex or forced you to have any sexual contact you did not want?” If yes: “How often does this happen?”
    • “Has your husband (or partner) threatened to kill you?” If yes: “How often does this happen?”

    If she answers “yes” to any of these questions, take a complete history, which will be covered in the next module.

  • Knowledge Check (5 min)

    1When a survivor shares her account of GBV, all of the following are key principles to follow, except:

    2When interacting with child survivors, which of the following things should you do? Select all that apply.

    3In the text box, list 2-3 things you can do to ensure privacy and maintain confidentiality. Then click or tap the compare answer button.

    4Put the following steps in order of how you should introduce the topic of violence.

  • Reading: Key Points (5 min)

    Here are some key points from this module.

    • Signs of violence may be direct and obvious (injuries, bleeding) or indirect (unexplained health problems, emotional and mental health issues).
    • It is important to make the survivor feel safe and respected during the clinical encounter.
    • All staff providing care must maintain the patient’s privacy and keep the patient’s information, including their identity, location, the circumstances of their assault, and the clinical notes, confidential.
  • References
    • 1WHO. Responding to intimate partner violence and sexual violence against women: WHO clinical policy and guidelines. 2013. P 24.
    • 2WHO. Health care for women subjected to intimate partner violence or sexual violence: A clinical Handbook. 2014 pp 8-9.
    • 3WHO. Health care for women subjected to intimate partner violence or sexual violence: A clinical Handbook. 2014 p 28.
    • 4WHO. Health care for women subjected to intimate partner violence or sexual violence: A clinical Handbook. 2014 p 36.
    • 5WHO. Health care for women subjected to intimate partner violence or sexual violence: A clinical Handbook. 2014 p 11.
    • 6WHO. Health care for women subjected to intimate partner violence or sexual violence: A clinical Handbook. 2014 p 11.
    • 7South African Government. The Children's Act No. 38 of 2005. Pretoria: Government Printer, 2005.