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J Youth Adolescence ;— Montgomery E. No single factor explains why some people are violent towards others or why violence occurs more frequently in some communities than in others.

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Nevertheless, it is possible to pick out a range of causes that are common to the various forms of violence. These causes are risk factors that can help predict when acts of violence might arise. They result from the complex interaction of individual, relational, social, cultural and environmental factors.

At the same time, it would seem simplistic to highlight the physical, psychological and social consequences that apply to every victim of violence. On the other hand, there are signs those intervening can look for that indicate it is likely an act of violence has been committed against an individual. Some authors have used this model to understand the factors associated with different forms of gender-based violence Thus it has been shown that certain individual characteristics — biological factors, personal history, etc. These characteristics influence the type and scale of the violence in each context.

They are heightened by the different levels of authority and power that are assigned to each sex and that maintain privilege and subordination among members of a society. The table below84 illustrates certain factors that favour intimate partner violence. Such violence can also be the product of influences exerted on behaviour at multiple levels. It is important to understand and take account of these risk factors when designing effective, long-term strategies for preventing and responding to gender-based violence.

Moreover, knowledge of the major repercussions of gender-based violence can make it easier to uncover those signs that point to the possibility of such acts and therefore easier to recognise those individuals who are victims. While the consequences of violence can be classified by type, they are often interdependent and depend on the individual concerned, the nature of the consequences and circumstances of the violence.

Generally, the classifications distinguish between the fatal and non-fatal consequences of gender-based violence. Murder — honour killings, feminicide, etc. As a result of its link to reproductive health, sexual violence has direct and indirect consequences that are particular to it. The direct consequences include physical injury that has an impact in reproductive health, particularly resulting from damage to reproductive and genital tissue.

They may, however, also arise as a result of emotional distress following rape that prompts risky sexual behaviour. This is an example of the indirect consequences of sexual violence cf. Women in this situation are therefore prepared to opt for a clandestine, non-medical termination that poses a major risk of death or illness. The consequences of such non-medical abortions include: haemorrhaging, infections, poisoning due to the use of substances to trigger the abortion and internal traumatic lesions.

They may also result in major complications requiring surgery notably fistulas , cause irreversible sterility or even be fatal. It has been shown that 38 women undergo a non-medical abortion every minute and that one woman dies every eight minutes as a In addition to the 65 to 70 deaths recorded each year as a result of non-medical abortions, it is believed that 5 million women undergoing the procedure subsequently suffer from temporary or permanent disability.

Social and economic consequences. It can thus lead to the disintegration of communities and to desocialisation. Existing traditional social cohesion may be undermined. The loss of moral points of reference can also render violence commonplace and give rise to general feelings of insecurity, sometimes reinforced by a culture of impunity. National legal frameworks.

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The usefulness of medical certificates. Who can issue a medical certificate? Direct access: to whom can a medical certificate be issued? When can medical certificates be issued? Financial and geographical barriers to access. Anyone involved in working on MdM programmes is likely to encounter individuals who are or have been victims of gender-based violence.

As a result, whatever the context or the project, each service provider should be trained to identify and receive such individuals. Preliminary identification and reception are crucial for ensuring good quality multidisciplinary care and support medical, psychological, legal and social. They enable victims to be dealt with directly or to be referred to another service provider. Those responsible must therefore be well informed about the different existing and accessible services for the care and support of victims of gender-based violence.

The first interview is crucial, particularly where violence is involved: a bond of trust must be established to ensure that the individual concerned will attend the full care and support. The first contact must also enable other acts of violence to be prevented by implementing appropriate, emergency protection measures in keeping with the gravity of the situation. Lastly, the individual must, at the first interview, be directed towards other services that may be required, provided that they are available, accessible and of a good quality.

These principles of patient reception concern all those involved with caring and supporting victims at every stage, both within the context of general medicine that includes care for victims of gender-based violence and within specialist structures. Each care provider must therefore receive training in the principles of patient reception applying to initial patient contact and to all subsequent interviews equally.

The principles of patient reception are based on ethics, but also relate to other precepts associated with certain communication techniques. Wearing badges or displaying messages in waiting rooms. The language used throughout the interview must be clear, comprehensible avoiding technical terms and reassuring so that verbal communication wins the trust of the patient. It is also essential to think of non-verbal communication as a way for the care provider to build a relationship with the victim. Non-verbal communication means assigning significance to various gestures and behaviours such as physical appearance, dress, movements, posture, look, etc.

Basic principles It takes a lot of courage for victims of violence to overcome their feelings of fear, guilt, and isolation and to dare to seek care and support. The way victims are received must not discourage them from taking the initiative. Listening Firstly, the care provider must listen to the individual. Although actively engaged in listening, the care provider must show respect and not cast doubt on or correct what is said, as showing doubt is a further form of aggression.

Empathy Empathy is the key to listening attentively and respectfully. This approach makes it possible to understand the ideas of the patient without subscribing to them, Confidentiality An environment must be created in which the individual can feel at ease and have the confidence to talk. To ensure that this happens, every interview must ideally begin with a one-to-one session to determine if the person really does want to be counselled and supported, and by whom.

If this approach is adopted by the organisation, notice of the protocol should preferably be posted, so that everyone understands that it is standard procedure and that no one coming with the victim is personally targeted by a refusal to be received during this first stage of caring for an individual.

In some situations, it can be impossible for a person often a woman to come to a consultation unless accompanied by a member of the family, which undermines the confidentiality of the exchanges. These social and cultural constraints must be taken into account. Generally, any coming or going is to be avoided throughout the interview.

Some patients prefer to have the door to the interview room closed for greater privacy. Others, in contrast, like to have the door left open, particularly where the care provider is of the opposite sex. It is essential to understand the expectations of the individual and to respect these. Lastly, the principle of confidentiality is constrained by the use of interpreters in instances where the care provider and the patient do not speak the same language.

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A document signed by the interpreter at the same time as the work contract must include a confidentiality clause. It is perhaps the first time that the person has recounted the facts. Paper produced by Josse Evelyne, clinical psychologist. Facilitate access to community services Be familiar with the resources available locally: emergency services, temporary shelters, etc.

Respect confidentiality All discussions must take place in private. This is essential for earning the trust of victims and ensuring their safety. Listen to and What dit they do in believe them. Lots a place of safety of other people have had similar if obliged experiences. Respect their Acknowledge autonomy the injustice Respect their right to The violence that take decisions that affect victims have suffered their progress when ready is not their fault and they to do so.

The individual is do not deserve violence. Normalize victimization Fail to respond to description of violence. Accept intimidation as normal in relationships. Do you have a place to go if things get worse? Speak to victims in front of other people. Speak to other care providers without victims consent about issues raised in confidence.

Call the police without their consent. Fail to take the danger seriously. Assume that if a person has put up with violence for years, it cannot be serious. Criticize victims Ask what they did to provoke the violence. Focus on them as the problem: why not just leave? During the initial interview, the issue of protection must be tackled. The effectiveness of the overall care and the quality of the relationship between the caregiver and the victim of violence depend on the latter being and feeling safe. The protection afforded during initial and ongoing care must be effective, notably as regards respecting confidentiality.

The worker also has a more general duty of care as regards the seriousness of the violence suffered and its potential reoccurrence. Respecting confidentiality throughout the care pathway protect victims from renewed violence that might arise when individuals outside perpetrator, family members, etc. Information can leak out as a result of members of staff being indiscreet.

Respect for the professional code of confidentiality is paramount and only essential and relevant information may be shared with other staff directly involved in providing care There is a greater or lesser risk of violence reoccurring depending on the circumstances. The level of seriousness of the violent situation must be assessed to determine whether emergency protection measures need to be put in place, or whether the public authorities need to be notified of the situation. In situations of heightened risk, different strategies may be drawn up in partnership with the victim. Drawing up a safety plan It is not easy to talk about the violence one has suffered and it is even more difficult to quit a violent environment.

Where there is repeated and often increasingly severe violence, such as in cases of intra-family violence90, some protection measures can be implemented in advance as part of a safety plan:. Children, who are old enough to understand, must be told of these measures so that they know what to do should the need arise. Some countries have strategies in place to combat genderbased violence, which facilitate implementation of personal safety plans for victims of violence. In France, the law related to violence against women, domestic violence and their consequences on children has been voted unanimously by the National Assembly and the Senate on 9th July It marks in particular a new stage concerning the protection of the persons undergoing domestic violence.

It gives to the judge the means to prevent violence and their recurrence with the device of the prescription of protection of the victims. The electronic monitoring system will be also set up. This system anti-link can be ordered when a violent partner is indicted for violence or threats, punished of at least 5 years. He will allow ensuring surveillance 24 hours a day, 7 days a week, days a year.

Temporary shelter for victims of violence Among the temporary protection measures that are available, the provision of temporary accommodation is often considered in extreme cases where it is essential to remove the victim from the author of violence. Proposals are currently being developed to introduce temporary shelters for perpetrators rather than victims of violence.

This measure would place responsibility for the situation firmly on the aggressor and on the aggressor alone. The victim would not have to leave home for an unknown destination nor have to see everyday life — including that of the children in the case of intimate partner violence — turned upside down. Since the adoption in December of the federal law designed to increase the protection offered by the civil courts to victims of violence, law enforcement agencies in Germany can, where there is a clear and imminent threat, oblige anyone carrying out acts of domestic violence to leave the family home and forbid them from returning for several days.

Temporary shelters may be perceived as places of protection. They may also, however, be viewed by the general population and by victims of violence as places of imprisonment, places that stigmatise or places of violence. Some women are, therefore, afraid that staying in a shelter will mean being excluded from the community.

They often dread the moment when they have to leave. Preparations must be made to mitigate the dislocation an individual experiences between life inside the shelter access to care, psychological support, balanced meals, etc. A commonly raised issue is the risk of experiencing the same violence again on leaving the shelter. MdM regional workshop on providing care and support for women victims of violence, Cairo Egypt , September Identifying victims is often problematic, as violence remains a taboo subject, particularly where it occurs within the family or where it is sexual in nature.

Care providers must therefore know how to detect these signs that point to violence and must maintain a proactive approach in dealing with it. In the context of gender-based violence, Setting up mechanisms for improving identification of victims of violence must be accompanied by provisions for their care and support either direct or indirect via partner organisations. In victims of violence Care providers must know how to recognize these various signs, interpret some in relation to others and take account of their cumulative significance; the more of them there are, the more likely a diagnosis of violence is correct, and the more likely the violence is serious and chronic.

Awareness-raising and training for professionals involved is crucial to ensure they have the necessary skills to spot these signs and thereby identify victims of violence. Signs of a psychosocial nature Mood and behaviour state of shock, disorientation, confusion, demonstrates a slowness in their behaviour, anxiety phobias, panic attacks, avoidant responses , depression sadness, selfharming, suicidal tendencies , is on edge, insomnia, loss of appetite, memory and concentration issues, mutism, abusing psychoactive drugs, excessive concerns about hygiene, isolation, etc.

The lack of staff training in identifying victims has led to serious situations arising. A year and a half after the initial consultation, the patient was admitted to intensive care for a ruptured spleen caused by blows from her partner. Focusing on treatment for her hepatitis and hypertension, none of the doctors seen raised the issue of violence as a possible cause of her psychosomatic complaints.

Testimony from one actor intervening in the frame of missions in France MdM France. Is this what happened to you as well? Some behaviour may suggest that an individual has committed, or may commit, acts of violence. Professionals must therefore pay close attention to the behaviour of a person accompanying a patient.

When viewed in conjunction with suspicious signs already observed in a patient, this behaviour can help identify a violent situation. Given too that victims of violence and particularly sexual violence are very often stigmatised by their community, they are reluctant to reveal the violence they have suffered. It is nevertheless possible to explore certain avenues as a way of identifying violent situations. Wearing badges or posting notices in waiting rooms or specific areas are examples of tired and tested methods.

How professionals intervene must be looked at carefully to gauge the feasibility and appropriateness of such initiatives and to adapt the way they are implemented. Screening is a method often used in medical settings for identifying victims of violence. This method can prove beneficial both for victims of violence and the professional involved. Likewise, a few simple questions may be enough to help the victim confide.

It is recommended that a screening protocol be implemented that takes account of linguistic nuances and socio-cultural determinants that apply to the given context. Before applying the screening process involving all service users, the professional staff can test it with a selection to see for themselves if the initiative proves effective.

This technique for identifying victims of violence entails staff training and awareness-raising for the whole organisation providing the care.

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Is this a problem that you have? Screening can contribute to early and more effective identification of violence and can encourage victims to acknowledge their situation more readily. The use of such a method could prevent incidents from escalating or reoccurring and thus reduce morbidity and mortality associated with gender-based violence. More particularly, this approach facilitates identification of victims of violence and their access to care and support services As a result of their privileged position, those providing community-based support can offer more accessible resources and have a better knowledge of the community.

They must be made aware of the issues surrounding gender-based violence and be informed of existing provision of care and support in order to be able to refer victims and perpetrators identified. Questions must always be asked as to the appropriateness of using community links and the choice of community-based provider. Some may themselves be victims or aggressors, while others may no longer hold a privileged position in the community.

The MdM programme in Liberia relied on some women with a traditionally privileged role within the community. Today, some of the women admit that their social standing is diminishing and that their role as advisers to the younger generation is no longer so effective. They close their eyes to intimate partner violence as a result of the way they perceive the role of women in the home. Many are also involved in harmful traditional practices carried out on girls and young women genital mutilation.

Dispensing medical care provides one of the opportunities for identifying and caring for victims of gender-based violence. It is founded on ethical principles and on a sequence of essential steps — interview, clinical examinations and paraclinical tests, treatment, etc. Healthcare staff is thus often the first provider that victims encounter. An ability to identify victims of violence and the quality of their reception and care are therefore crucial for ensuring that they will continue to attend the full care and support.

Medical care is nevertheless just one opportunity among others. In this instance, the medical staff is requisitioned to dispense appropriate medical care. Ethics examine the hierarchy of values and the criteria governing choice, particularly in the field of healthcare They serve as points of reference for health professionals and a failure to observe them constitutes professional malpractice.

Ethical principles on the other hand are a general undertaking to respect human rights. Duty to treat people without discrimination This entails providing treatment and care irrespective of race, ethnicity, nationality, gender, religion or beliefs, social group, political affiliation, mores, family situation, reputation, disability, wealth and state of health. Delivery of emergency treatment is the only criterion for prioritising care. This entails inflicting no unnecessary suffering by act or omission. Free and informed consent Service users must understand the stages of care — interview, examination, treatment, photographing, etc.

Consent is considered free when it is obtained without threat, constraint or illegal incentive. It must be informed, that is to say preceded by accurate, comprehensible and full information presented on what the proposed treatment involves. It is not enough to provide the information: it is imperative that the doctor ensures the patient has correctly understood it. Free and informed consent does not imply that it must always be explicitly formulated: for medical procedures and brief examinations that pose no significant risk to the patient, tacit or implicit consent is enough in instances where there is no doubt that it is being given.

In the case of certain medical procedures, however, national legislation requires written consent. Example: Under French law, any patient having to undergo a coloscopy must give written consent in advance consent form. Minors also have the right to receive clear and accurate information. Their opinion must always be sought and taken into account in relation to their degree of maturity and understanding Their consent alone is, however, not sufficient and their parents or other legal representative guardian exercising parental responsibility must be consulted.

In certain circumstances intrafamily violence, prostitution, sexual violence, etc. An alternative solution to informing the parents should therefore be found and a trusted adult designated by the minor should be sought for support. The interests of the child must always take precedence and guide the healthcare worker.

This is even more crucial in violence cases. Medical confidentiality applies to the collection, circulation and archiving of data. No personal details should be disseminated, except between members of the same network of care providers. Multidisciplinary care and support involves different members of a network working together.

In such cases, the sharing of information is acceptable if it is done in the interests of the patient shared professional confidentiality. In terms of medical ethics relating to confidentiality, each care provider must share only necessary and relevant information. Medical confidentiality must also be guaranteed in the suitable layout of premises, ensuring a minimum of privacy for consultations. The issue of confidentiality similarly arises where an interpreter is required.

If the individual does not request a certificate, the doctor has a duty to offer one, stressing the usefulness and significance of a medical certificate. For care providers, protecting does not mean systematically reporting acts of violence of which they are aware. Such measures are only appropriate where the individual concerned has fully consented.

The obligation to obtain consent may be waived for the purposes of protecting the patient: thus, the systematic reporting of children suffering abuse is often recommended. The same applies to cases of torture or other inhuman or degrading treatment involving individuals in prison. For particularly vulnerable individuals person with a disability, dependent elderly person, person in a controlling relationship, etc. The particular circumstances of each case must take precedence over the systematic reporting of abuse. Certain prerequisites exist that ensure the quality of care dispensed.

Over and above training for medical interventions, healthcare staff must also be trained to identify, receive and refer patients An ideal medical care and treatment pathway may be summarised in the following diagram: Interview Clinical examination. General information Personal details For more information, see the two sections relating to receiving and identifying on pages and Description of incident The description of the incident, relayed by the doctor, is a transcript of what the patient says.

Under no circumstances does it reveal any bias on the part of the doctor. Where the situation allows for forensic examination to be carried out, some further information may be gathered in cases of rape washing after the assault, sexual intercourse since the assault and how often, etc. Some people prefer also to be examined by The clinical examination of victims of violence comprises three stages.

The use of a body diagram on which to record all details relating to each physical injury is recommended. This involves systematically describing the exact location of all wounds and injuries. Haematomas take a minimum of forty-eight hours to appear, particularly on black skin.

The absence of physical signs does not imply the absence of violence. In such cases, some precautions must be followed: the doctor must avoid certain procedures — e. In any case involving a young girl, the use of instruments for genital examination is not recommended. Paraclinical tests Complementary tests must be carried out depending on the results of the clinical examination and resources available.

These may involve biological tests in cases of sexual violence blood tests, HIV rapid serological test, STI screening, urine These different tests can have a forensic purpose concerning the perpetrator or the circumstances of the violence when used as part of judicial procedures Do not gather evidence that cannot be processed or used.

In the case of paraclinical tests, abide by the protocols methods for sampling, labelling, storing, etc. Do not hand over samples to the authorities if the individual does not wish to press charges. Medical details As is the case with every patient, healthcare staff receiving victims of violence must supply clear information on the methods for taking medication and on any possible side effects. Moreover, staff must advise patients of other existing care and support services that they might need.

Treating physical injuries Where there is an open, weeping wound to the skin or mucous A treatment is referred to as curative when it involves topical procedures such as cleaning, suturing wounds only when they are clean and within forty-eight hours of an attack or prescribing antibiotics when the wounds are dirty and cannot therefore be sutured. In some victims of sexual violence, physical lesions may include fistulas. As fistulas cause serious medical complications, the physical examination requires working alongside a doctor with the appropriate expertise.

Where a fistula is confirmed or suspected in a woman surviving a sexual assault, she must be referred to a centre that offers surgical treatment to repair fistulas. Fistulas can only be repaired by surgical procedure, unless the lesion is very recent. Medical treatment must take into account these different potential consequences.

Refer to national guidelines where they exist. Where such documents do not exist, medical teams may then refer to the MdM guidelines which may also be collated with those of other NGOs operating in the area. Always opt in favour of the shortest and most readily implemented treatment.

The vaccine presents no contra-indications for pregnant women or anyone suffering from a chronic illness such as HIV. It can be administered at the same time as the anti-tetanus vaccine. Screening must nevertheless be offered to any victim of rape, regardless of the time that has lapsed. If the test is negative or is refused by the individual, post-exposure prophylaxis PEP must be offered if, and only if, the rape occurred recently.

Post-exposure prophylaxis PEP is only effective and appropriate if administered within 3 days of the sexual violence. Post-exposure prophylaxis comprises two or three antiretroviral drugs ARVs to be taken over a period of twentyeight days. Tritherapy is the preferred treatment but where it is unavailable bitherapy should be used.

As prophylactic treatment is only effective in the three days following a rape, it is absolutely essential to run awarenessraising and information campaigns for the local population on the time limits prescribed for the care of sexual violence. The population must also be informed that, even if a period of seventy-two hours has elapsed, medical treatment for sexual violence remains crucial. Treating the risk of pregnancy and pregnancy resulting from rape Emergency contraception Medical care for victims of rape involves preventing unwanted pregnancies that may result.

An emergency contraceptive pill should therefore be offered. Again, this is a matter of personal choice that can only be made by the woman concerned. The doctor has a duty to inform victims of the issues surrounding emergency contraception, while taking account of how contraception and abortion are perceived in the context. It must also be explained that the emergency pill has to be prescribed within a maximum of three days following the rape, as its effectiveness diminishes over time.

The emergency contraceptive pill acts by disrupting the reproductive cycle.

It does not terminate nor damage an existing pregnancy. The World Health Organisation does not consider it to be a method of abortion A positive pregnancy test reveals the presence of a hormone that is not secreted until ten days after sexual intercourse. Thus, a pregnancy detected within ten days of a rape must be the result of sexual intercourse that took place before the incident. The victim was already pregnant at the time of the incident. Moreover, the emergency contraceptive pill cannot prevent pregnancy resulting from sexual intercourse that takes place after treatment.

The doctor must therefore recommend contraceptive use as soon as possible, if the woman does not wish to have a baby. The question of pregnancy termination If a patient is pregnant as a result of being raped, the question arises of whether the unwanted pregnancy should be terminated. Here again, knowledge of the context is crucial as regards the legal framework abortion in cases of rape not permitted, abortion for minors without the consent of legal representatives not permitted, etc. The healthcare staff may also examine the legislation for any loophole that might make a legal termination possible.

Legal exceptions nevertheless do exist for therapeutic reasons: to save the life of a woman where she is in danger, or where there is the risk of serious deformity in the unborn child. In the case of a pregnancy resulting from rape, abortion is not allowed unless the rape was an act of terrorism. Despite these prescriptions, and given that pregnancy resulting from rape can have serious repercussions on the mental health of the woman, a certain number of doctors use the loophole offered by the legal right to perform therapeutic abortions.

In so far as is possible, this should include putting the woman in touch with reproductive health services emergency treatment in the event of complications, family planning advice, etc. In cases where termination is strictly forbidden, some women may wish to turn to illegal means to obtain an abortion. They then run the risk of procedures carried out in dangerous conditions that do not guarantee their medical safety untrained staff, unsatisfactory hygiene, etc. Healthcare staff, like the population in general, should be aware that psychological consequences following an act of violence are common and can be severe These symptoms must be taken into account.

In many cases, victims of violence succeed in overcoming their emotional difficulties. Where the opposite occurs and they develop psychological problems, more complex support must be available and the doctor must be able to refer the patient to a competent professional — psychologist, psychiatrist, psychiatric nurse, etc.


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All victims of violence should not automatically be referred. Mild tranquilisers or anti-depressants may be prescribed as an option alongside psychological care, if the latter proves insufficient. Such medication must, however, be used with caution and always prescribed by competent medical staff.