International Journal of Gynecology and Obstetrics 128 (2015) 87–88
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
FIGO COMMITTEE REPORT
Ethical guidance on healthcare professionals’ responses to violence against women FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health
The FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health considers the ethical aspects of issues that impact the discipline of obstetrics, gynecology, and women’s health. The following document represents the result of that carefully researched and considered discussion. This material is intended to provide material for consideration and debate about these ethical aspects of our discipline for member organizations and their constituent membership. B. Dickens, Chair FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health E-mail: figo@figo.org Website: www.figo.org Bernard Dickens University of Toronto Faculty of Law 84 Queen’s Park Toronto M5S 2C5, Canada Tel.: +1 416 978 4849 Fax: +1 416 978 7899 E-mail: [email protected]
Background 1. The UN defines violence against women as "any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private life” [1]. This may also include verbal violence such as insults, threats or shouted commands or condemnation. 2. The range of violent conduct that women experience should not be underestimated, because its effects are not always directly physical. Emotional injury may induce clinical depression or anxiety, or lead to substance abuse and comparable forms of self-harm, including attempted suicide. 3. A comprehensive WHO study reported that 35.6% of all women worldwide will suffer physical or sexual violence in their lifetime, usually from a male partner [2]. The WHO Director-General observed that such reports show that violence against women is a global health problem of epidemic proportions, as a matter both of public health and clinical care. Violence against women is found everywhere, not particular to any national, geographical, racial, ethnic, religious, or socioeconomic group. It is a violent offence against women's health, and against women’s human rights. 4. In addition to risks of violence that women face from their domestic or intimate partners, vulnerable or socially marginalized women are at increased risk. Sources of risks vary, for instance assailants exploiting positions of authority, and assaults during social turmoil, military conflict, and other conditions of lawlessness. This may occur in the context of governmental and/or community indifference. Evidence shows violence against women to be a strategic instrument in intercommunal or armed strife, and to occur widely for instance in refugee camps, including by “peacekeeping” forces. 5. Sexual violence against women has special relevance to gynecologists and obstetricians. It can lead to unintended pregnancy, and its termination, whether by safe and legal means or by unsafe means, when women are or feel isolated. Women’s termination of pregnancy is more likely to present health risks when it is illegal. Sexual violence can also lead to other gynecological problems, such as direct injury to the reproductive tract, or sexually transmitted infections including HIV. Violence during pregnancy increases the likelihood of spontaneous abortion, stillbirth, preterm delivery, and the birth of low birth-weight babies. 6. The 2013 WHO clinical and policy guidelines highlight “the critical role that the health system and health-care providers can play in terms of identification, assessment, treatment, crisis intervention, documentation, referral, and follow-up” [3]. The guidelines observe that “although violence against women has been accepted as a critical public health and critical care issue, it is still not included in the health-care policies of many countries,” and appears “poorly understood or accepted within national health programs and policies” [3]. The guidelines further point to deficiencies in healthcare professional education that leave providers ill-equipped to deal effectively with patients victimized by domestic, strangerinitiated, or other violence. 7. Despite providers’ commonly inadequate preparation for case management, evidence shows that women who have experienced violence are more likely than nonabused women to seek health care. Healthcare providers are often the first contacts for survivors of violence and
http://dx.doi.org/10.1016/j.ijgo.2014.10.004 0020-7292/© 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
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B. Dickens / International Journal of Gynecology and Obstetrics 128 (2015) 87–88
sexual assault. Assaulted women often identify healthcare providers as the professionals they most trust with disclosure of such abuse. Gynecologists may be preferred because they may examine patients in privacy, in the absence of, for instance, husbands or mothersin-law. They therefore have a responsibility to equip themselves to respond to patients’ needs, and to keep confidentiality. 8. Patients may not be immediately forthcoming about violence they have experienced. Thus, gynecologists and their staff members may encounter more women victims of violence than they realize. However, the 2013 WHO guidelines [3] observe that “universal screening” or “routine enquiry” should not be implemented, meaning that women should not be asked in all healthcare encounters about their exposure to violence or sexual assault as routine, but that judgment should be exercised in each case. 9. Jurisdictions vary on whether reporting of violence against women is mandatory, on which care-givers are obliged to report, and to which agencies reports must be submitted. Even where reporting is not legally compelled, however, involved nongovernmental organizations and international human rights agencies consider it necessary that such violence be documented, to link suspected offenders to injuries, and to facilitate interventions and support advocacy on behalf of victims. Recommendations 1. Member societies of FIGO should support the prequalification and postqualification training of all relevant healthcare providers, particularly gynecologists, obstetricians, midwives, and nurses, in identification of women who have experienced intimate partner or other violence and sexual assault. This may be through direct training programs, continuing professional education, or universitybased or comparable courses, modelled, for instance, on the 2013 WHO guidelines [3] and other authoritative guidance. 2. Training should address the eliciting and diagnosis of the type of violence, including when and how to enquire about a patient’s history or threat of suffering violence, and how to collect forensic evidence if required in the doctor − patient setting. Training should also include a basic knowledge about violence, including relevant laws, available community and other support for victims, and (in) appropriate attitudes among healthcare providers 3. When women disclose violence, healthcare professionals should assess their conditions, asking questions when necessary to improve the diagnosis and the women’s immediate and subsequent care. Clinical care should be woman-centered, with clinicians offering support that includes consultation in private with maximum confidentiality, being nonjudgmental, and validating patients' narratives through careful, respectful listening. Enquiries about their experience of violence should not pressure women to talk, be guarded when interpreters are involved, aim to increase safety for patients and their children when needed, and help patients to access available resources.
4. Care for victims should, as far as possible, be integrated into existing services rather than stand as separate services in order to avoid stigmatization and improve access, with health systems giving priority to service delivery at the primary care level, to assure broad access to knowledgeable care. Healthcare providers unable to offer first-line support should promptly refer women to accessible alternative sources. 5. Women presenting shortly after sexual assault should be offered appropriate protection against sexually transmitted infections and emergency contraception. If presenting later or emergency contraception fails, women should be offered abortion services in accordance with applicable law. Care options for patients pregnant at the time of assault should be discussed with them, and administered in conformity with their choices. 6. Personnel who have religious or other objections to advising, prescribing, administering, or participating in indicated treatment should comply with FIGO Ethical Guidelines on Conscientious Objection to ensure timely treatment on patients’ requests. 7. Providers should also consider and set up longer-term care, provide emotional support, and refer patients to relevant information and available services, such as for depression, post-traumatic stress disorder, anxiety, substance addiction, and unexplained chronic pain. Responses to patients’ concerns should not intrude on patients’ autonomy, but provide choices for help and self-help. Plans for follow-up care should be discussed with patients to monitor their conditions and interventions that the providers and/or other caregivers have administered. 8. Laws mandating reporting evidence of violence have to be followed, but otherwise providers should not report incidents or conditions of violence as a matter of routine. They should discuss with their patients the implications of mandatory reporting, and options of voluntary reporting, for instance to agencies able to offer protection or relief. They should ensure their patients’ awareness of their rights, and follow their preferences on disclosure. 9. If laws that mandate reporting are considered harmful, providers should advocate their reconsideration or refinement. London, March 2014
References [1] United Nations. General Assembly. ACB/RES/48/104. Declaration on the elimination of violence against women. http://www.un.org/documents/ga/res/48/a48r104.htm; December 20, 1993. [2] World Health Organization. Violence against women: Intimate partner and sexual violence against women. Factsheet No. 239. Updated October 2013. http://www. who.int/mediacentre/factsheets/fs239/en/. [3] World Health Organization. Responding to intimate partner violence and sexual violence against women: clinical and policy guidelines. Geneva: WHO; 2013. http:// apps.who.int/iris/bitstream/10665/85240/1/9789241548595_eng.pdf?ua=1.
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
FIGO COMMITTEE REPORT
Ethical guidance on healthcare professionals’ responses to violence against women FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health
The FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health considers the ethical aspects of issues that impact the discipline of obstetrics, gynecology, and women’s health. The following document represents the result of that carefully researched and considered discussion. This material is intended to provide material for consideration and debate about these ethical aspects of our discipline for member organizations and their constituent membership. B. Dickens, Chair FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health E-mail: figo@figo.org Website: www.figo.org Bernard Dickens University of Toronto Faculty of Law 84 Queen’s Park Toronto M5S 2C5, Canada Tel.: +1 416 978 4849 Fax: +1 416 978 7899 E-mail: [email protected]
Background 1. The UN defines violence against women as "any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private life” [1]. This may also include verbal violence such as insults, threats or shouted commands or condemnation. 2. The range of violent conduct that women experience should not be underestimated, because its effects are not always directly physical. Emotional injury may induce clinical depression or anxiety, or lead to substance abuse and comparable forms of self-harm, including attempted suicide. 3. A comprehensive WHO study reported that 35.6% of all women worldwide will suffer physical or sexual violence in their lifetime, usually from a male partner [2]. The WHO Director-General observed that such reports show that violence against women is a global health problem of epidemic proportions, as a matter both of public health and clinical care. Violence against women is found everywhere, not particular to any national, geographical, racial, ethnic, religious, or socioeconomic group. It is a violent offence against women's health, and against women’s human rights. 4. In addition to risks of violence that women face from their domestic or intimate partners, vulnerable or socially marginalized women are at increased risk. Sources of risks vary, for instance assailants exploiting positions of authority, and assaults during social turmoil, military conflict, and other conditions of lawlessness. This may occur in the context of governmental and/or community indifference. Evidence shows violence against women to be a strategic instrument in intercommunal or armed strife, and to occur widely for instance in refugee camps, including by “peacekeeping” forces. 5. Sexual violence against women has special relevance to gynecologists and obstetricians. It can lead to unintended pregnancy, and its termination, whether by safe and legal means or by unsafe means, when women are or feel isolated. Women’s termination of pregnancy is more likely to present health risks when it is illegal. Sexual violence can also lead to other gynecological problems, such as direct injury to the reproductive tract, or sexually transmitted infections including HIV. Violence during pregnancy increases the likelihood of spontaneous abortion, stillbirth, preterm delivery, and the birth of low birth-weight babies. 6. The 2013 WHO clinical and policy guidelines highlight “the critical role that the health system and health-care providers can play in terms of identification, assessment, treatment, crisis intervention, documentation, referral, and follow-up” [3]. The guidelines observe that “although violence against women has been accepted as a critical public health and critical care issue, it is still not included in the health-care policies of many countries,” and appears “poorly understood or accepted within national health programs and policies” [3]. The guidelines further point to deficiencies in healthcare professional education that leave providers ill-equipped to deal effectively with patients victimized by domestic, strangerinitiated, or other violence. 7. Despite providers’ commonly inadequate preparation for case management, evidence shows that women who have experienced violence are more likely than nonabused women to seek health care. Healthcare providers are often the first contacts for survivors of violence and
http://dx.doi.org/10.1016/j.ijgo.2014.10.004 0020-7292/© 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
88
B. Dickens / International Journal of Gynecology and Obstetrics 128 (2015) 87–88
sexual assault. Assaulted women often identify healthcare providers as the professionals they most trust with disclosure of such abuse. Gynecologists may be preferred because they may examine patients in privacy, in the absence of, for instance, husbands or mothersin-law. They therefore have a responsibility to equip themselves to respond to patients’ needs, and to keep confidentiality. 8. Patients may not be immediately forthcoming about violence they have experienced. Thus, gynecologists and their staff members may encounter more women victims of violence than they realize. However, the 2013 WHO guidelines [3] observe that “universal screening” or “routine enquiry” should not be implemented, meaning that women should not be asked in all healthcare encounters about their exposure to violence or sexual assault as routine, but that judgment should be exercised in each case. 9. Jurisdictions vary on whether reporting of violence against women is mandatory, on which care-givers are obliged to report, and to which agencies reports must be submitted. Even where reporting is not legally compelled, however, involved nongovernmental organizations and international human rights agencies consider it necessary that such violence be documented, to link suspected offenders to injuries, and to facilitate interventions and support advocacy on behalf of victims. Recommendations 1. Member societies of FIGO should support the prequalification and postqualification training of all relevant healthcare providers, particularly gynecologists, obstetricians, midwives, and nurses, in identification of women who have experienced intimate partner or other violence and sexual assault. This may be through direct training programs, continuing professional education, or universitybased or comparable courses, modelled, for instance, on the 2013 WHO guidelines [3] and other authoritative guidance. 2. Training should address the eliciting and diagnosis of the type of violence, including when and how to enquire about a patient’s history or threat of suffering violence, and how to collect forensic evidence if required in the doctor − patient setting. Training should also include a basic knowledge about violence, including relevant laws, available community and other support for victims, and (in) appropriate attitudes among healthcare providers 3. When women disclose violence, healthcare professionals should assess their conditions, asking questions when necessary to improve the diagnosis and the women’s immediate and subsequent care. Clinical care should be woman-centered, with clinicians offering support that includes consultation in private with maximum confidentiality, being nonjudgmental, and validating patients' narratives through careful, respectful listening. Enquiries about their experience of violence should not pressure women to talk, be guarded when interpreters are involved, aim to increase safety for patients and their children when needed, and help patients to access available resources.
4. Care for victims should, as far as possible, be integrated into existing services rather than stand as separate services in order to avoid stigmatization and improve access, with health systems giving priority to service delivery at the primary care level, to assure broad access to knowledgeable care. Healthcare providers unable to offer first-line support should promptly refer women to accessible alternative sources. 5. Women presenting shortly after sexual assault should be offered appropriate protection against sexually transmitted infections and emergency contraception. If presenting later or emergency contraception fails, women should be offered abortion services in accordance with applicable law. Care options for patients pregnant at the time of assault should be discussed with them, and administered in conformity with their choices. 6. Personnel who have religious or other objections to advising, prescribing, administering, or participating in indicated treatment should comply with FIGO Ethical Guidelines on Conscientious Objection to ensure timely treatment on patients’ requests. 7. Providers should also consider and set up longer-term care, provide emotional support, and refer patients to relevant information and available services, such as for depression, post-traumatic stress disorder, anxiety, substance addiction, and unexplained chronic pain. Responses to patients’ concerns should not intrude on patients’ autonomy, but provide choices for help and self-help. Plans for follow-up care should be discussed with patients to monitor their conditions and interventions that the providers and/or other caregivers have administered. 8. Laws mandating reporting evidence of violence have to be followed, but otherwise providers should not report incidents or conditions of violence as a matter of routine. They should discuss with their patients the implications of mandatory reporting, and options of voluntary reporting, for instance to agencies able to offer protection or relief. They should ensure their patients’ awareness of their rights, and follow their preferences on disclosure. 9. If laws that mandate reporting are considered harmful, providers should advocate their reconsideration or refinement. London, March 2014
References [1] United Nations. General Assembly. ACB/RES/48/104. Declaration on the elimination of violence against women. http://www.un.org/documents/ga/res/48/a48r104.htm; December 20, 1993. [2] World Health Organization. Violence against women: Intimate partner and sexual violence against women. Factsheet No. 239. Updated October 2013. http://www. who.int/mediacentre/factsheets/fs239/en/. [3] World Health Organization. Responding to intimate partner violence and sexual violence against women: clinical and policy guidelines. Geneva: WHO; 2013. http:// apps.who.int/iris/bitstream/10665/85240/1/9789241548595_eng.pdf?ua=1.
