Cover Image
close this bookViolence against Women (WB)
close this folderAppendix
View the documentAppendix A. recommendations for government action to combat violence against women
View the documentAppendix B: definition of violence against women
View the documentAppendix C: methodology for estimating the healthy years of life lost due to domestic violence and rape
View the documentAppendix D: sample danger
View the documentAppendix E Treatment protocols for battered women

Appendix A. recommendations for government action to combat violence against women

Actions for the national secretariat on women

1. In consultation with women's NGOS working on gender violence issues, develop e national initiative against violence against women. (Countries that do not have a high-level office dedicated to advancing the status of women should consider establishing one.)

2. Provide financial and technical support to NGOs that provide services to and perform advocacy on behalf of victims of violence, especially those working from a feminist perspective. Work with women's NGOs to develop strategies to expand the availability of services for victims-from both governmental and non-governmental sources-including shelters, crisis centers, legal assistance, counseling, and support groups.

3. Work with other ministries to implement a coordinated campaign against violence against women, including all of the activities outlined below.

4. Work to improve women's access to productive resources, including land, credit, wage employment, and child care.

5. Sponsor a national media campaign designed to communicate social norms that define violence against women as unacceptable.


Actions for the ministry of health

1. Establish and implement model protocols for the early identification and referral of abuse victims in health care settings, including emergency rooms and primary care facilities such as family planning and prenatal clinics. Train staff in counseling, examining victims, and collecting legal evidence for prosecution.

2. Undertake research on the incidence and prevalence of gender-related violence, the percentage of women presenting indifferent health settings who are abused, the mental health consequences of violence, and the health care costs of domestic violence and rape.

3. Integrate questions on gender violence into national health surveys and into ongoing research in such areas as AIDS, sexuality, and family planning. Colombia incorporated questions on family violence into its Demographic and Health Survey, and the Philippines is planning to do likewise. The module needs to be improved and its use funded.

4. Introduce consciousness-raising material and training on the dynamics of abuse (including culture bound practices that are harmful) into the curricula and professional licensing exams for such health care workers as doctors, psychologists, nurses, and midwives. Integrate similar themes into the training of community based health promoters.

5. Establish, through research, a clinical profile detailing injuries, location, and other symptoms-of women presenting with abuse to help health workers identify victims.

6. Incorporate themes related to all forms of gender-based violence and sex role stereotyping into radio shows, soap operas, and other educational materials now being used to promote family planning, AIDS education, awl other health themes.

7. In collaboration with the ministry of justice, sponsor sensitivity training for forensic doctors on violence against women and on bow to collect and document evidence of assault, sexual abuse, and rape.

8. Discourage destructive drinking and illicit drug use among adolescents and adults by sponsoring educational programs and skills training on resisting peer pressure.

9. Expand treatment programs for individuals addicted to drugs and alcohol.

  1. Implement treatment and reeducation programs for perpetrators.


Actions for the ministry of justice

1. Sponsor legislation that specifically criminalizes domestic violence, marital rape, and other crimes against women. Eliminate inappropriate legal responses, such as the "honor defense," which exculpates perpetrators of wife murder and infanticide.

2. Reform existing laws to facilitate prosecution of genderbased crimes such as rape and domestic assault. Amend laws that interfere with the ability of women to escape violent relationships (for example, barriers to divorce).

3. Document how laws related to gender violence are (or are not) enforced, detailing the frequency of prosecution, arrest rates, judgments, and sentences.

4. Amend laws and regulations, as needed, to allow any licensed health care provider to examine and collect evidence of physical and sexual assault for legal purposes.

5. Extend and improve medical and legal services provided by the state for victims of violence in both urban and rural areas.

6. Require all crime statistics to be broken down by gender (for both the perpetrator and the victim). Information should also be recorded on the relationship between the perpetrator and the victim to help identify the gendered nature of violent crime.

7. Support NGOs providing human rights education and legal literacy training for women.

8. Implement training programs on gender based violence for the police, prosecutors, and judges.

9. Incorporate gender-awareness training and analysis into law school curriculum.

10. Take measures to increase the number of women police officers, lawyers, prosecutors, and judges. Ensure the availability of female officers and forensic doctors for gender-violence-related investigations and exams.


Actions for the ministry of education

1. Remove gender bias and gender stereotyping from school curriculum and teaching materials.

2. Integrate gender awareness training, parenting skills, and nonviolent conflict resolution into school curricula

3. Work with the media to portray positive images of equitable relationships and to remove gratuitous violence from the media.

4. Provide gender-awareness training to teachers and educators and teach them to recognize the signs of abuse.

Appendix B: definition of violence against women

Despite the existence of a worldwide movement against gender-based violence, there is no single definition of violence that guides all activists. The main point of contention is how broadly to define the term. Some argue for a very broad definition that includes any act or omission that causes harm to women or keeps them in a subordinate position (see, for example, the definition in the draft Pan American Treaty against Violence). Under such a definition, any structural feature that perpetuates gender based discrimination could arguably qualify as violence.

The appeal of a broad definition is that it would permit many violations of women's human rights to be addressed under the rubric of violence. But the danger is that in throwing the net so widely, the descriptive power of the term is lost. Calling everything violence- poverty, pornography, trafficking in women, lack of access to schooling-makes it easier to discount the issue entirely and to justify inaction on the more specific forms of abuse, such as rape and wife assault. (It is rather like the justification that since everything causes cancer anyway, one might as well smoke.) This is not to say that unequal pay and lack of access to safe abortion, for example, are not violations of women's human rights, but we must ask what explanatory power is gained by calling these violations violence.

An overly broad definition limits the usefulness of the term for describing such traditional forms of violence as rape and wife assault. We have a word to describe gender inequalities-discrimination. And we have a word that captures much of what activists call structural violence-poverty. But no other term collectively defines those acts of force or coercion, perpetrated by individual men, that cause physical and emotional harm to women. Thus, I would argue for a more limited definition, recognizing full well that violence is just one of many violations of women's human rights.

The United Nations Declaration against Violence against Women avoids making difficult distinctions by offering a tautology in place of a definition. According to the declaration, violence against women is "any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivations of liberty, whether occurring in public or private life." It then offers a list of abuses that presumably meet the definition (appendix box B. 1). But the list is not exhaustive, and it leaves unanswered the fundamental question of what constitutes gender-based violence.

The United Nations list of abuses does represent an adequate compromise between a desire to be inclusive and the need to keep the definition specific, however. It includes only acts perpetrated by an individual or the state and excludes laws, policies, or structural inequalities that could be construed as violent (laws against abortion, structural adjustment policies). But the UN definition provides insufficient guidance to determine whether items that are not listed, such as female feticide or restrictive abortion policies, would constitute gender violence

What would constitute an adequate definition of violence? Any definition must have at its center the core concepts of force and coercion, which distinguish between violent and merely oppressive behavior. But to what extent should violence be limited to physical force? Dictionary and public health definitions of violence tend to focus exclusively on physical force. Webster 's Ninth Collegiate Dictionary for example, defines violence as "the exertion of physical force so as to cause injury or abuse." Concentrating on physical force provides a clear demarcation between violence and other acts, but it excludes many behaviors-such as psychological abuse and humiliation-that activists and women generally include in their definitions of violence.

Indeed, studies have shown that battered women often rate emotional abuse by their partners as more injurious than physical assault( Casey 1988). To exclude verbal and psychological abuse would be to deny an important facet of women's victimization.

It remains, however, to distinguish between random violence and violence that is gender-based. Clearly, the notion of violence against women does not include violence directed toward men or directed toward women for reasons unrelated to their sex (for exemple, an assault during a robbery). What distinguishes violence against women is force or coercion (whether verbal or physical) that is socially tolerated in part because the victims are female. At times this force may be consciously applied to perpetuate male power and control; at other times that intent may be missing, but the effect nonetheless is to cause harm in a way that reinforces female subordination.

The case of genital mutilation underscores the importance of arguing for a definition of violence that rests on the notion of physical and psychological harms rather than on the express intent of the perpetrator. Although most parents do not subject their daughters to female circumcision with a conscious desire to harm, the effect of the practice-intended or not-is to physically, psychologically, and sexually maim young girls. Moreover, parents proceed with the operation knowing full well that it will cause pain and suffering, even though this may not be their primary motivation (see the definition offered in Asia Pacific Forum on Women, Law and Development 1990, which hinges specifically on the intent of the perpetrator).

In keeping with the above discussion, I propose to define violence against women as:

Any act of verbal or physical force, coercion, or life threatening deprivation, directed at an individual woman or girl, that causes physical or psychological harm, humiliation or arbitrary deprivation of liberty and that perpetuates female subordination.

This definition has a number of important advantages. By referring to acts directed at an individual girl or woman, it helps distinguish between acts of violence and harmful policies that may damage the health of women as a class but are not directed at a particular individual (for example, lack of investment in women's health research). By including life-threatening deprivation along with force or coercion, the definition includes systematic neglect of girl children in cultures that value sons over daughters. This type of deprivation (including with holding of food and medical care) leads directly to death and starvation on a significant scale, and it is perpetrated against individual girls, distinguishing it from other acts of omission that more properly constitute discrimination or structural inequality (for example, lack of access to schooling). Finally, the clause "and perpetuates Female subordination" speaks to the social consequences of the violence and helps distinguish random violence from gender-based violence.

The definition includes the phrase "arbitrary deprivation of liberty" to accommodate such acts as forced isolation or excessively controlling behavior by a batterer -acts that fail to respect women as autonomous, adult human beings. Some men use violence or threats of violence to exert almost total control over their wives' mobility and their access to money and other material resources. Such behavior can reach excessive and dangerous proportions.

Appendix box B.1 Definitions of violence against women

Behavior by the man, adopted to control his victim, which results in physical, sexual and/or psychological damage, forced isolation, or economic deprivation or behavior which leaves a woman living in fear. (Australia 1991)

Any act involving use of force or coercion with an intent of perpetuating /promoting hierarchical gender relations. (Asia Pacific Forum on Women, Law and Development 1990)

Any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivations of liberty, whether occurring in public or private life. Violence against women shall be understood to encompass but not be limited to:

Physical, sexual and psychological violence occurring in the family and in the community, including battering, sexual abuse of female children, dowry related violence, marital rape, female genital mutilation and other traditional practices harmful to women, non spousal violence, violence related to exploitation, sexual harassment and intimidation at work, in educational institutions and elsewhere, trafficking in women, forced prostitution, and violence perpetrated or condoned by the State. (UN Declaration against Violence against Women)

Any act, omission or conduct by means of which physical sexual or mental suffering is inflicted, directly or indirectly, through deceit, seduction, threat, coercion or any other means, on any woman with the purpose or effect of punishing or humiliating her or of maintaining her in sex-stereotyped roles or of denying her human dignity, sexual self-determination, physical, mental and moral integrity or of undermining the security of her person, her self-respect or her personality, or of diminishing her physical or mental capacities. (Draft Pan American Treaty against Violence against Women)

Any act or omission which prejudices the life, the physical or psychological integrity or the liberty of a person or which seriously harms the development of his or her personality. (Council of Europe 1986)

Appendix C: methodology for estimating the healthy years of life lost due to domestic violence and rape

The calculation of the disability-adjusted life years (DALYs) lost due to domestic violence and rape is based on estimates of the share of life years lost to premature mortality and that can be attributed directly to gender-based victimization. The burden of disease is the net present value of the future stream of disability caused by incident cases in 1990 plus the future stream of healthy life lost from premature mortality from 1990 deaths by disease condition. A 3 percent per year discount rate is assumed in the exercise to translate future years of life lost into their present value. Non-uniform age weights are also assumed, but because the loss of life is valued according to the future stream of age specific weights and not just the weight of one year, the results of the analysis are not very sensitive to the introduction of non-uniform age weights. To equate morbidity and mortality, the global burden of disease (GBD) exercise assigns "disability weighting factors (between 0.02 and 0.9) to conditions based on their interference with normal enjoyment of life and functioning. A rating of 0.02 represents minimal interference with well-being and productivity, and weightings of 0.6 and higher represent major life dislocations, with 0.9 appropriate only for conditions just short of death, such as coma.

A full discussion of the methodology, including the estimation of incidence by region and by age group and assumptions about disability weights, age-weighting, and the discount rate, is contained in Murray forthcoming and Murray and Lopez forthcoming.

Since domestic violence and rape are not diseases per se, the GDB frames gender-based victimization as a risk factor that increases the incidence of certain other morbidities and conditions, such as physical traumas and depression. Thus, the calculation of DALYs lost to genderbased victimization begins with the GDB estimates of DALYs lost due to each condition and then estimates the percentage of the total for that condition attributable to domestic violence or rape. (An analogy would be estimating the proportion of disability resulting from emphysema, lung cancer, and heart disease that can be attributed to smoking.)

Appendix table C.1 summarizes the estimates of attributable risk used to calculate the DALYs lost due to rape and domestic violence. The evidence supporting each percentage estimate is on file with the World Bank GBD team. The DALYs lost to each condition is multiplied by the percentage attributable to gender victimization and then summed across conditions. The total DALYs lost to domestic violence and rape can then be compared to totals calculated for different disease categories, such as tuberculosis and malaria.

The table gives estimates only for DALYs lost due to rape and domestic violence among women age 15 to 44. Thus it excludes DALYs lost due to other gender-based forms of victimization, such as genital mutilation.

Appendix table C.1 Disability-adjusted life years lost to women age 15 to 44 due to conditions attributable to domestic violence and rape

Relevant conditions

Total DALYs lost to women age 15 to 44 (millions)

Share attributable to domestic violence and rape

STDs (excluding HIV)

15.8

2 percent

HIV

10.6

2 percent

Abortion

2.5

10 percent

Depression

10.7
(men age 15 to 44) 5.4

50 percent of difference between women and men

Alcohol dependence

0.9

10 percent

Drug dependence

1.1

10 percent

Post-traumatic stress disorder

2.1

60 percent

Unintentional injures

6.7

20 percent of total burden minus burden attributable to motor vehicle accidents and occupational injuries;

Suicide

5.5

30 percent

Homicide

0.9

60 percent

Intentional injury

1.2

90 percent

Total

58.0

6 percent

Source: World Bank data.

Appendix D: sample danger

[This sample danger assessment is from Campbell 1986.]

Several risk factors have been associated with homicides (murder) of both batterers and battered women as a result of research that was conducted after the killings tool: place. We cannot predict what will happen in your case, but we would like you to Ix aware of the danger of homicide in situations of severe battering and for you to see how many of the risk factors apply to your situation. (The "he" in the questions refers to your husband, partner ax-husband, expartner, or whoever is physically hurting you.) Please circle the relevant answer below.

1. Has the physical violence increased in frequency over the past year?

YES - NO

2. Has the physical violence increased in severity over the past year and/or has a weapon or threat with a weapon been used?

YES - NO

3. Does he ever try to choke you?

YES - NO

4. Is there a gun in the house?

YES - NO

5. Has he ever forced you into sex when you did not wish to do so?

YES - NO

6. Does he use drugs (cocaine, crack heroin, uppers or other street drugs)?

YES - NO

7. Does he threaten to kill you and/or do you believe he is capable of killing you?

YES - NO

8. Is he drunk every day or almost every day (in terms of quantity of alcohol?)

YES - NO

9. Does he control most of your daily activities? For instance, does he tell you who you can be friends with, how much money you can take shopping or when you can have the car?

YES - NO

10. Have you ever been beaten by him while you were pregnant? (If never pregnant by him, check here. )

YES - NO

11. Is he violently and consistently jealous of you? For instance does he say, "If I can't have you, no one can?"

YES - NO

12. Have you ever threatened or tried suicide?

YES - NO

13. Has he ever threatened or tried suicide?

YES - NO

14. Is he violent toward your children?

YES - NO

15. Is he violent outside the home?

YES - NO

Total "YES" answers


Appendix E Treatment protocols for battered women

This article is reprinted with the permission of Response.
NURSING NETWORK ON VIOLENCE AGAINST WOMEN

Treatment protocols for battered women

WENDY K TAYLOR AND JACQUELYN C. CAMPBELL

Battering of an intimate partner is a widespread social problem occurring on a daily basis (Varvaro, 1989). Society has a tendency to look upon spouse abuse as a private matter" or "love spat" that will soon be over. This is not the case. It is rare for a violent episode between intimates to happen only once (Varvaro, 1989). Over time the violence escalates, becomes more frequent, and seventy of injury increases (Varvaro, 1989; Stark, Flitcraft & Frazier, 1979).

Research conducted by McLeer and Anwar (1989); Stark. Flitraft, and Frazier (1979); and Goldberg, and Tomlanovich (1984) indicate that 25 percent-33 percent of female trauma injures were the result of battering. Stark and Flitcraft (1985) have found that domestic violence accounts for more injuries to women than rapes, muggings and motor vehicle accidents combined. In general, it is believed that the severity of injury is greater in domestic violence cases than injuries sustained in stranger assault (Varvaro, 1989).

In 1980 the National Crime Survey (NCS) reported that 30,000 visits to emergency rooms, 40,000 physician visits, 21,000 hospitalizations, and 100,000 days of hospitalization were associated with domestic violence (McLear and Anwar, 1989; Varvaro, 1989) More than one million women per year seek medical care for injuries caused by battering (Deckstein and Nadelson, 1986) Traumatic injuries from family violence range from mild to life threatening. Injuries include, but are not limited to, bruises in various stages of healing fractures, black eves, ear injures, abdominal injuries, miscarriages related to trauma to the abdominal area, stab wounds, gunshot wounds, head trauma, and suicide attempts (Campbell and Sheridan 1989; Varvaro, 1989; and Helton, McFarlane, and Anderson, 1987).

Many battered women do not need or seek medical attention for their injuries. Of those seeking medical care only one in ten is officially identified as a battered woman by health care professionals (Randall, 1990; Varvaro, 1989; Stark, Flitcraft, & Frazier, 1979) Once identified, the treatment of battered women by health care personnel may be a positive response, a negative response, or non-existent (Varvaro, 1989). Kurz and Stark (1988) have found evidence of inappropriate responses- to battered women by the medical profession. Their findings indicate that in most cases the battering is denied or its importance is diminished. They also found that battering was not a high priority for health care providers. Medical responses to battered women tend to focus on the physical injuries caused by battering and have a tendency to blame the victim for the violence (Kurz & Stark, 1988; Varvaro, 1989; Campbell and Sheridan, 1989; Rosewater, 1988). Reasons for inappropriate responses or no response by the health care professional may stem from lack of knowledge or training in abuse issues, misinformation /myths, sexist bias, the structure of the medical model (Gampbe'l and Sheridan, 1989; Kurz, & Stark, 1988), and disbelieving the woman's story (Hilberman, 1980). Research has indicated that a positive response from the health care provider may enable the battered woman to take steps in ending a violent relationship and choosing a nonviolent alternative lifestyle for her children and herself (Campbell and Sheridan, 1989; Varvaro, 1989).

Nurses, physicians, arid other health care providers are in an ideal setting to intervene with battered women Unidentified battered women have increased health problems and make more frequent visits to health care facilities (Campbell and Sheridan 1989; and Varvaro, 1989). All females, regardless of presentation, should be assessed for battering. The majority of battered women will discuss the violence in their relationships if asked. It is important to treat not only the battered woman's physical injures but attend to her emotional needs as welt Always interview the woman alone and reassure her that she is safe in disclosing this information to you. Most battered women will feel a sense of relief that someone believes them and is willing to offer assistance. It is of utmost importance to document the history of the current abusive incident and past abuses in her medical record. State in her medical record who injured her. All battered women should receive a complete physical exam, including a neurological exam and x-rays to identify old and new fractures. Be sure to assess for possible sexual abuse by her partner. Document all physical findings. If at all possible, photograph the woman's injures. You will need to obtain signed consent to photograph. If unable to photograph, use a body map to indicate location of current injuries and past injuries. If the battered woman has children. assess for child abuse. The battered woman needs to be informed of her rights according to state laws, and she should be given referral information for counseling and shelters (Campbell and Sheridan, 1989; and Varvaro, 1989).

The development and use of a written policy and protocols increased the identification of battered women more than five-fold in one urban emergency department (McLeer & Anwar, 1989). In another emergency department of a large, urban university hospital, Tilden and Shepherd (198;') tested an interview protocol used by emergency room staff nurses when assessing female trauma patients. The researchers wanted to determine if using a systematic protocol that directly questioned women as to who caused their injury, would lead to an increase in the identification of battered women. Data were collected from the medical records of all female trauma patients for a 4 month period prior to implementing protocols in order to establish a baseline. After training the nurses in the use of the protocol, data were again collected for a 4-month period. The total N for the pre and post- training was 72 and 74 respectively. Post training rate of identification was significantly higher 22. 9 percent) than the pre-training rate of 9.72 percent (Tilden & Shepherd, 1987).

McLeer and Anwar (1987) reviewed the records of every fourth female trauma case during 1976 who presented to the emergency room of the Medical College of Pennsylvania A total of 359 medical records were reviewed. The results indicated that 5.6 percent were classified as positive for battering, 10 9 percent were probable battered women, and 9 2 percent suggestive of battering. A protocol containing questions eliciting a trauma history and whether someone was responsible for causing a woman's injuries was developed. The emergency room nurses were trained to use this protocol. After training and implementation of this protocol, 412 emergency room records were examined. The authors report that positive identification for battering increased from 5.6 percent to 30 percent after implementation of staff training and use of protocols (McLeer, & Anwar, 1987).

TABLE 1 Accreditation Manual for Hospitals, 1992 Emergency Services

In 1986 McLeer & Anwar conducted a follow-up study at the same emergency room. They found the identification rate or battered women was significantly lower in 1985 than in 1977. The protocol implemented in 1977 was no longer in effect. Since the patient population had not changed, the authors concluded that without a monitoring system to ensure continued use, implementation of a written policy and protocols were not sufficient for continued vigilance on the part of staff in identifying battered women (McLeer & Anwar, 1989).

Goldberg and Tornlanovich (1984) conducted a study using 492 male and female emergency room patients. The purpose of their study was to obtain information on the extent and nature of domestic violence in the emergency room patient population. Data were collected through chart audit and a self-administered questionnaire. The results indicated that 22 percent of the patients identified themselves as victims of domestic violence on the questionnaire but only 5 percent were identified as such in their emergency room records. The data from these studies indicate that development of protocols, the implementation of protocols, and education of staff in using the protocols increases the rate of identification of battered women.

The Joint commission for the Accreditation of Health Care Organizations (JCAHO) has mandated that hospitals develop and implement policies and procedures for the identification, assessment, treatment, evaluation, and referral of battered women and the abused/neglected elderly. The mandate became effective January 1, 1992. A copy of the new JCAHO emergency department criteria has been included to assist you in the development and writing of protocols specific to your state and institution (Tables 1 and 2).

Following is a brief synopsis of protocols and training

ES5.1.2 10 the handling of adult and child victims of alleged or suspected abuse or neglect.
ES.5.1.2.10.1 Criteria are developed for identifying possible victims of abuse.
ES.5.1.2.10.1.1 The criteria address at least the following types of abuse:
ES5.1.2 10.1.1.1 physical assault;
ES.5.1.2.10.1.1.2 rape or other sexual molestation; and
ES.5.1.2 10.1.13 domestic abuse of elders, spouses, partners and children
ES5.1.2.10.2 Procedures for the evaluation of patients who meet the criteria address: ES.5.1.2.10 2 1 patient consent;
ES.5.1.2. 10.2. 2 examination and treatment;
ES.5.1.2 10 2.3 the hospital's responsibility for the collection, retention. and safeguarding of specimens, photographs, and other evidentiary material released by the patient, and
ES5.1. 2 10 2 4 as legally required, notification of, and release of information to. the proper authorities.
ES.5.1 2.10.3 A list is maintained in the emergency department/service of private arid public community agencies that provide, or arrange for, evaluation and care for victims of, abuse. and referrals are made as appropriate
ES.5.1.2.10.4 The medical record includes documentation of examinations, treatment given, any referrals made to other care providers and to community agencies, and any required reporting to the proper authorities.
ES.5.1 2.10.5 There is a plan for education of appropriate staff about the criteria for identifying, and the procedures for handling possible victims of abuse.

TABLE 2 Accreditation manual for Hospitals, 1992 Hospital-Sponsored Ambulatory Care Services

HO.3..2.15 The handling of adult and child victims of alleged or suspected abuse or neglect.
HO.3 2.15.1 Criteria are developed for identifying possible victims of abuse:
HO.3 715.1.1 The criteria address at least the following types of abuse:
HO.3.2.15.1.1.1 physical assault;
HO.3.2.15.1.1.2 rape or other sexual molestation and
HO.3.2.15.1.1.3 domestic abuse of elders, spouses. partners, and children
HO.3.2.15.2 Procedures for the evaluation of patients who meet the criteria address:
HO.3 .2.15 2.1 patient consent;
HO.3 .215.2.2 examination and treatment,
HO.3.2.15 .2. 3 the hospital's responsibility for the collection, retention, and safeguarding of specimens, photographs, and other evidentiary material released by the patient; and
HO.3. 2.15.2.4 as legally required, notification of. and release of, information to the proper authorities.
HO.3 .2.15.3 A List is maintained in the ambulatory care services department of private and public community agencies that provide, or arrange for, evaluation and care for victims of abuse, and referrals are made as appropriate.
HO.3.2.15.4 The medical record includes documentation of examination, treatment given any referral(s) made to other care providers and to community agencies. and any required reporting to the proper authorities.
HO.3.2.15.5 There is a plan for education of appropriate staff about the criteria for identifying and the procedures for handling possible victims of abuse manual from various institutions nationwide used for the treatment of battered women in health care settings: Sivan, A. B. (Ed). (1990). Child Abuse, Sexual Assault & Domestic Violence: Guidelines for Treatment in Emergency and Primary Medical Settings. Order from: Metropolitan Chicago Healthcare Council, 222 S. Riverside Plaza, Chicago, L 60606, (:312) 906-6000. (Goss of this manual is $75.00 for members of the Metropolitan Chicago Healthcare Council; $95.00 for tax-exempt non-members; and $:102 60 for all others. There is also a 55.00 postage and handling charge on all orders.)

This manual is a joint publication of the Metropolitan Chicago Healthcare Council, the Chicago Metropolitan Battered Women's Network' and Chicago Sexual Assault Services Network. It updates and replaces, Guidelines for the treatment of battered women victims in emergency room settings, authored by Sheridan. Belknap, Engel, Katz, and Kelleher (1985). The revised edition comes in a three ring binder. It was primarily written for use by emergency room personnel, but is applicable and adaptable to any clinical setting. It is comprehensive in its scope as it includes treatment guidelines for child abuse and neglect; child sexual assault; battered women; elder abuse; adult sexual assault; and a discussion entitled, Staff reactions to problems of domestic violence and child

The manual is divided into four sections. Each section begins with facts; followed by types of common and subtle injuries indicative of abuse; assessment, treatment and management issues; documentation; and prevention strategies. The four sections include Illinois statutes and acts related to the type of abuse, sample protocols, injury maps, selected references, and a list of referrals to community agencies which provide services to battered women, their children, and sexual assault survivors.

Colorado Department of Health, and Colorado Domestic Violence Coalition (1991). Domestic violence: A guide for health care providers, (ord Ed) For ordering information contact Colorado Domestic Violence Coalition, P.O. Box 18902, Denver, CO 80218. (303) 573 9018.

This is a comprehensive guide for health care providers that can be adapted to any health care setting. The manual comes in a three ring binder and is divided into seven sections, including an appendix. It is a practical, as well as informative, "how to" guide Section I provides an introduction, an overview of the problem, and facts/objectives. Section II discusses the legal responsibilities of health care personnel. Section m covers the context, characteristics, dynamics, costs, and effects of battering. Identification assessment, documentation, and intervention are addressed in Section IV. Section V provides specific guidelines for developing, implementing and maintaining a protocol. An extensive bibliography is listed in Section VI. In Section VII the reader will find a list of resources, contacts, and training films. Several articles related to battering are included in the appendix. The resources and statutes referred to in this manual are specific to Colorado.

King, C, and Ryan, J. (1991). Woman abuse advocacy protocol. Order from Christine King Ed D, RN, School of Nursing, University of Massachusetts, Arnold House, Amherst, MA 01003. (413) 545- 2703.

The advocacy protocol is a brief, yet precise guide for nurses and social workers intervening with battered women. Included are communication techniques for interviewing the abused woman; type of information to be documented in the medical record; specific services available to battered women; a section on legal rights and options; various types of counseling alternatives; assessment for risk of homicide and discussing safety strategies/ plan; ways to help the battered woman establish a support network; and methods to empower the woman when closing. This protocol will be appearing in an upcoming issue of the American Journal of Nursing.

Also written by King Ryan, and Perri, (1987), is a training manual for nurses entitled, Reaching Out To Battered Women, Stone Circle Press. The manual includes information on assessment, intervention, documentation, and referral. For a copy, refer to the above address.

Foley, Hoag, and Eliot. (1991). Empowering battered women: suggestions for health care providers. Order from: Massachusetts Coalition of Battered Women Service Groups, 107 South Street, 5th Floor, Boston, MA 02111, (617) 426-8492 (Cost is $12.00 per copy plus $2.90 for postage and handling.)

An educational manual written by attorneys in the Foley, Hoag and Eliot Abuse Prevention Program aimed at health care professionals. The authors provide information on the dynamics of battering relationships; ways health care workers can identify, assess, intervene, document, and refer battered women. Also included are sections on battering and pregnancy; signs of increasing danger; legal remedies; and community resources available to battered women. Several programs from various states that treat men who batter can be found on page .

Appendix A contains an extensive reference list of journal articles and books. Appendix B provides several articles related to abuse issues. Appendix C lists national and state information and resource centers Esposito, C.N. (1990). Domestic violence: a guide for health care professionals (3rd printing). Order from Domestic Violence Prevention Program, Division on Women, NJ. Department of Community Affairs, 101 S. Broad Street, CN 801, Trenton, New Jersey 08625 0801, Attention Nora Vista Shuda. (this manual is currently in the process of being revised to reflect the changes in the law. The revised edition will be available after January 1, 1992).

A comprehensive manual for use by nurses, physicians, social workers: and hospital security departments. It is further divided into two parts. Part I is a model protocol. The first section of the manual provides an introduction to the problem of wife abuse. The second section emphasizes a multidisciplinary approach to treating battered women. Discussions focus on crisis intervention techniques, the physical exam, confidentiality/ privacy, documentation, photographing injuries, evidence collection and preservation, referrals, legal responsibilities of health care professionals, and the effects of implementing a battered woman policy. The next section covers identification of adult victims of battering and elder abuse. The last section addresses the roles and responsibilities of various health care personnel from the emergency room secretarial staff to the public health nurse.

Part II offers a model curriculum for identification, treatment, and referral of adult victims of domestic violence. Suggestions are presented for speeches and audiovisuals. Topics under the model curriculum include the dynamics of domestic violence, definitions, an historical perspective, statistics, causes, and myths. Also included are community resources for battered women, types of protection/options available to victims under New Jersey law, presenting the protocol, group sessions, offering of a question & answer period, and type of summary $ evaluation necessary to complete the course. The entire manual is 54 pages plus 29 pages of appendices.

Emergency Department, Maine Medical Center. (1990). Identification, treatment, and referral of abused women. To order a copy contact Emmy L. Hunt, M.S.N., RN, CEN, Head Nurse, Department of Emergency Medicine, Maine Medical Center, 22 Bramhall Street, Portland, Maine 04102, (207) 871 4624.

The emergency department at Maine Medical Center implemented an abused woman protocol in 1990. Prior to implementation, all emergency department personnel attendees educational sessions. The protocol uses a multidisciplinary approach to treating battered women. Included in this protocol are sections on identification of battered women; interventions specific to nursing, medicine, and social services; common injuries; documentation and photographing of injuries; privacy; danger assessment; safety plan; and referrals. The protocol is aimed primarily at emergency department personnel but can easily be adapted to other clinical settings.

Helton, AS. (1987). Protocol of care for the battered woman : Prevention of battering during pregnancy. For ordering information contact March of Dimes, Birth Defects Foundation, Professional Education Department, 1275 Mamaroneck Ave., White Plains, NY 10605, (914) 42 7100, or Anne Stewart Helton, RN, M S., ACCE, Clinical Associate, Prevention of Battering During Pregnancy, Texas Woman's University, 1130 M.D. Anderson Blvd, Houston TX 77030.

A guide primarily for nurses to detect pregnant women who are battered. This comprehensive manual provides: an overview of battering; specifics on battering and pregnancy; common indicators related to battering; a body map for indicating site of injury; abuse assessment tool written in English and Spanish; information on documenting in the medical record; and prevention strategies. 1 he March of Dimes produced a video tape which can be used in conjunction with this protocol entitled, Crime Against the Future. The video tape can be rented or purchased. Contact the March of Dimes for further information graham, R. Furniss, K., Holtz, H., and Stevens, M.E. (1986). Hospital protocol on Domestic Violence. They also authored, Hospital training on domestic violence. Both can be ordered from Jersey Battered Women's Services, Inc. 36 Elm Street, Morristown, NJ 07960.

The hospital protocol was written for use in the emergency department but is easily adaptable to other settings. The manual is comprehensive and quite specific. A multidisciplinary approach is used. The roles and responsibilities of nurses, physicians, social workers, etc. are given in detail. The manual is written in outline form and easy to follow. A short reference list of books, films journal articles, and publications is provided. The Hospital Training on Domestic Violence compliments the protocol manual. The entire curriculum requires a minimum of 35 hours. Included in the curriculum are specific behavioral objectives and outcomes; topics to be presented; method of instruction; evaluation mechanism; and materials needed.

Tomita, S., Clark, H., Williams, V., and Rabbitt, I (1982). Elder abuse and neglect protocol. To obtain a copy contact Karil Klingbeil, Department of Social Work, Harborriew Medical Center, Seattle, WA, (206) 223-3000.

A comprehensive protocol for social workers but easily adaptable to other disciplines. This protocol includes: definitions of elder abuse/neglect; criteria for social worker involvement; type of information necessary for complete history and documentation of this information; assess meet, diagnosis, and intervention strategies; desired outcome; and termination of social worker involvement. Attached to the protocol is a quality assurance checklist, and a copy of the Goldfarb Dementia Scale.

Rosenlieb KO. The emergency department care of the sexual assault victim (RAPE). Copies of the tape are available for a nominal fee. To order your copy contact: Kay O. Rosenlieb, RN, PhD, Chairperson Nursing Dept., Slippery Rock University, Slippery Rock, PA 16057.

This video tape was created and produced by Dr. Rosenlieb and three nursing students. The video tape highlights use or the rape evidence collection kit and the role of nursing. Dr. Rosenlieb uses the video in the Women's Health course.

WomanKind, Inc. Support systems for Battered Women. (1l992). WomanKind Emergency Department Protocol. To obtain a copy contact Susan M Hadley, M.P. H. Founder and Executive Director, WomanKind, Fairview Southdale Hospital/Fairview Ridges Hospital, 6401 France Avenue south, Minneapolis, MN 55435. (612) 924-5775.

This is a comprehensive guide for healthcare professionals. It is designed primarily for use in the emergency department but is easily adaptable to any clinical setting. The protocol begins with a brief introduction, followed by a discussion of specific behaviors, common injuries/ injury sites, and typical symptoms associated with battering. Section II provides more specific information on the interview process and treating not only the woman's physical injuries, but attending to her emotional needs as well. Privacy and confidentiality are the focus of Section m. Section IV elaborates on the importance of documenting the abuse history and any physical findings. The legal liabilities of health care professionals, procedures for photographing, and preservation of evidence are also discussed in this section. Section V contains a brief discussion about the correlation between substance abuse and domestic violence.

Each section provides sample questions necessary for obtaining and documenting a thorough history and physical findings. Also included with the WomanKind protocols is a list of The Battering Syndrome signs and symptoms; definition of terms related to battering with specific examples; and a bibliography.

Varvaro, F.F., and Cotman, P.B. (1986). Domestic vio fence: A focus on tire emergency room care of abused women. To order a copy contact Women's Center and Shelter of Greater Pittsburgh, P.O. box 9024, Pittsburgh, PA 15224. (412) 687 8017.

This comprehensive manual is written for emergency room personnel, but can be easily adapted to a variety of clinical settings. It is designed to be used as a classroom tool or for individual study. The manual begins with an Overview and Introduction which discussed the format (question and answer format); lists objectives; and defines terms used by the authors. The manual is further divided into four sections: Section-I-Nursing Intervention; Section Shelter Intervention; Section III-Primary Intervention; and Section IV-Bibliography. Each section provides in-depth information necessary for the health care professional to identify, assess, intervene, document, and refer battered women. Sample questions and situations are provided as guidelines. Characteristics and other pertinent information pertaining to abusers are discussed. The bibliography is extensive and annotated. The manual concludes with an 11 question short-answer post-test, including answers to the test.

REFERENCES

Campbeil. J C., and Sheridan. D J (1989) Emergency nursing interventions with battered women. Journal of Emergency Nursing, 15(1), 12 - 17

Deckstein, L.J.and Nadelson, CC (1986). Family Violence: Emergency issues of a national crisis. Washington, D.C: American Psychiatric Press,Inc.

Goldberg. W. and Tomlanovich. M.C. (1984). Domestic violence victims in the emergency department .Journal of the American Medical Association, 251(24). 3259 -3264.

Helton. AS.. McFarlane. J., and Anderson. E (1987). Battering during pregnancy: A prevalence study. American Journal of Public Health. 77(10), 1337-39.

Hilberman. E (1980). Overview: The "wife-beater's wife" reconsidered. American Journal of Psychiatry. 137. 1336-1347

Kurd. D. and Stack, E (1988) Not-so-benign neglect: The medical response to battering. In K Yllo & M. Bograd (Eds). Feminist Perspectives on Wife Abuse Newbury Park, CA: Sage Publications. Inc.

McLeer. S.V. and Anwar, R (1987) The role of the emergency physician in the prevention of domestic violence. Annals of Emergency Medicine. 16(10), 11551161.

McLeer, SV. and Anwar, R. (1989). Education is not enough: A systems failure in protecting; battered women. Annals of Emergency Medicine 18(6), 651-653.

Randall, I (1990). Domestic violence intervention calls for more than treating injuries. Journal of the American Medical Association. 264(8). 939-944

Rosewater, L.B. (1988) Battered or schizophrenic? Psychological tests can't tell. in K Yllo & M. Bograd (Eds), Feminist Perspectives on Wife Abuse. Newbury Park, Gl: Sage Publications, Inc.

Stark, E and Flitcraft, A. (1985). Woman-battering, child abuse and social heredity. What is the relationship? In N. Johnson (Ed), Marital Violence. Sociological Review Monograph #31. London: Routledge & Kegan Paul.

Stark. E. Flitcraft, A and Framer. (1979). Medicine and patriarchal violence: The social construction of a "Private. event. International Journal of Health Services, 9. 461-493.

iTilden, V.P and Shepherd, P. (1987). Increasing the rate of identification of battered women in an emergency department Use of a nursing protocol. Research, Nursing and Health, 10(4), 209- 15.

Varvaro, F.F. (1989). Treatment of the battered woman: Effective response of the emergency department. American College of emergency Physicians, 11, 8-9 & U.

Wendy K. Taylor, M.S., R.N is Coordinator, Family Violence Program, Department of Medical Nursing and Social Service Department, at Rush Presbyterian-St. Luke's Medical Center in Chicago. Jacquelyn C. Campbell, Ph.D, RN, FAAN, is Assistant Professor, Department of community Health Nursing, at Wayne State University.

The Nursing Networking Violence Against Women (NNVAW) is a flexible coalition of nurses and other concerned individuals engaged in advocacy, research, clinical practice, and/or education on issues related to violence against women. For membership informal on ($10/year) and/or to submit suggestions for articles, write to Jackie Campbell, Wayne State University College of Nursing, Detroit, MT 48202. See Conference Report for announcement of the next conference, May 17-19, 1991.

This article and others listing protocols can be found on the Response Data Base Disk.

Family Violence Program Grant Contributes to Prevention

A small grant from the Administration for Children and Families two years ago helped the New York State Coalition Against Domestic Violence respond to a request from women incarcerated in a New York facility and, in turn, generate other activities which are contributing to the prevention of family violence.

Gwen Wright, Director of the Coalition, explains that the HHS funds helped make it possible to hold a conference in response to a request from women at New York's Bedford Hills Correctional Facility Incarcerated women involved in the project were participants in the facility's Family Violence Program, an innovative program that helps women understand the nature of violent and abusive behavior and enables them to build skills that will be needed when they return to their homes

The women-imprisoned for crimes that had resulted from lifelong backgrounds of battering and other forms of abuse-wanted their Family Violence Program known about in other correctional facilities Women in the program earlier had conducted an informal survey that indicated that as many as 65 percent of incarcerated women at the facility had been abused Officials there believe the actual number is even higher.

Working in cooperation with the facility, the New York State Coalition Against Domestic Violence successfully applied for a grant which, in part, underwrote a conference at the Bedford Hills Facility Participants at the conference in addition to the incarcerated women, included representatives from correctional facilities and coalitions in several states As a result, a number of positive actions have occurred in the region

One action that followed the conference was the establishment of a task force that is studying sexual assault issues throughout the state Other initiatives included changes within the state's parole system One of the most important results of the conference according to Sharon Smolick, who directs the program at Bedford Hills, is that it has raised consciousness about the problem throughout the region's correctional community

A premise of the facility's program is that battered and sexually abused women who are incarcerated need program support comparable to that provided other women. The program at Bedford Hills has proved highly beneficial. "It's a good program," says Elaine Lord, Superintendent of the facility "We're very pleased with it "

The discretionary grant funding for this activity, which was provided through the Family Violence Prevention and Services Act Program, was $12,000.

-Family Violence and Sexual Assault Bulletin