1MEN’S AND WOMEN’S HEALTH – SEPTEMBER 27TH, 2007

WOMEN ABUSE (2ND LECTURE)

LECTURE 8

ALL SLIDES FROM THE WOMEN ABUSE LECTURES WILL BE SENT TO DR. URAZ
TO BE POSTED ON E-COLLEGE

Principles in disclosure:
• Listen without judgement: be mindful of facial expression
• Acknowledge disclosure: “glad you told me that”; “must be hard for you to tell me”; “takes courage”, etc.
• Discuss confidentiality: may have to tell supervisor in clinic. Assure you won’t tell partner/abuser directly, but you
have duty to report. Good to tell her in initial intake that there are times that we have to breach confidentiality. May
discuss with colleagues for example. In St. Joseph’s women’s centre, have to ask permission to talk to her doctor in
the same facility. If talking with someone outside of facility (eg. Psychiatrist, welfare worker), need woman’s
permission in writing.

Reasons to breach confidentiality:

• Kids in your care are being harmed;
• Actively suicidal: can send her to hospital, or send the police to her home
• Homicidal
• If a health-care provider is sexually abusing her (ie. Non-consensual sex with her spouse who is a health-care
worker): have to report to their governing board
• Say all of this in intake, far away from her disclosure

• Want to validate her feelings

• Normalize her experience “you’re not alone”
• Be mindful of your reaction.

• Meet her where she’s at: listen to what she needs, don’t rush her into shelter! “Where are you at with this?” She may
just want advice, may not leave for a year afterwards.
• Give options and info, not advice. Not “if I were in this situation, I would…” we have power in this situation. Let her
choose. It is for her to decide, not us.
• If you are taking notes, don’t let it take away from being present in the conversation. Maybe note 1 word to help you
remember details later.
• Assess for immediate danger: is she safe right now?
• If there is danger, help her develop a plan.

What NOT to say:

• Everything’s going to be okay! You can’t guarantee this. Many women are murdered by spouses: not okay.
• “Have you tried couples’ counselling?” might trigger abuse after session.
• “Did you do something to set him off?”
• “Have you told him you don’t like it?”
• excusing/rationalizing on his behalf
• “Maybe just take a break for a while?” this won’t help.
• “Calling the police will take care of everything”
• Don’t guarantee she will get complete custody of kids. He will likely get access to kids at least (and to her)

Assessment:
• Check your agenda at the door. Start where she is.
• Is there an immediate risk?
• Plan for today and the immediate future.
• Explore the risks and benefits of a different plan: staying with her sister 3 blocks away: is this safe?
• Children’s exposure to the abuse
• Provide referrals: you don’t need to be the one to do counselling. Have to respect if she doesn’t want to go forward.
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Risk assessment:
The Woman abuse council of Toronto has a tool for risk assessment (google this?). About 30 questions such as:
• When did the abuse start?
• When was the last incident? – not just physical abuse
• Has she been afraid for her life? Have there been death threats, incidents of choking?
• Where are the kids when he is abusive?
• Has he threatened or attempted suicide? Many cases of murder/suicide.

Most important question:

WHAT WILL HAPPEN WHEN YOU GO HOME TODAY? DO YOU FEEL SAFE RETURNING HOME TODAY?
If not, have to move to new level of care.

Does she have a plan? If not, ask if there is anywhere safe that she can go to? Familiar places are best: family, friends,
co-workers. Other option is shelter. Maybe call shelter and talk to them, even if there is no room

Emergency plan:
• If she decides to go back and then there is another incident, what is she going to do?
• Help her make a plan (but she is in control of this process)
• Recognize her strength: she has been surviving up to this point
• Respect her process and timetable.
• Acknowledge the steps that she has taken.

Crisis lines: if she isn’t ready to make changes, she can call for advice, counselling after she leaves office.

There is a woman abuse documentation form in clinic.

Documentation in domestic violence care centres is approved by justice system. Ours is for info only.

Duty to report:
If we hear the story, it is up to us to report (not delegated)
If CAS is being called, they will want to talk to the woman to make arrangements.

There are 4 child protection agencies in Toornto:

• Children’s aid society (CAS): They also have a domestic violence team: they will know how to handle abuser.
• Catholic children’s aid society
• Native child and family services
• Jewish child and family services.

DVERS: Domestic violence emergency response system: she wears an alarm, if she is approached she can call (eg. If
abuser has restraining order on him)
Law has changed: if she calls police and presses charges, it will go forward. Can’t then drop charges.

SEXUAL ASSAULT/ABUSE
• Not just “strangers” abusing women: frequent reports of sexual abuse in relationships. It is most commonly someone
she knows.
• Only 1% reported. 38% happen in her home

• Woman may present with genital trauma, STDs, chronic pelvic pain, PID, unwanted pregnancies
• She may be denied birth control: she can’t leave if she has 3 kids to worry about!

Impacts:
• Confusion. Shame and guilt. Fear of being alone, extreme fear of perpetrator, nightmares/insomnia,
depression/anxiety.
• Avoidance of physical exams, being touched by anyone (even partner if she is assaulted by someone else),
flashbacks, minimizing (I’m okay!), self-blaming (I should have…), anger
• Anger is good. May turn into action for her (counselling, police)

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Most don’t report:
• Offender is rarely convicted
• Concern about attitude of police/courts
• Thinks she won’t be believed
• Retraumatization in legal process
• Fear of retaliation after charges laid

Asking about sexual abuse

• Similar to other types of abuse
• Have you be assaulted at any time: may affect patient’s interaction with you now, even if attack was 10 years ago.

Vicarious trauma – be aware of:

• Identification with trauma/pain of patient
• Feelings of helplessness, guilt, anger.

Make sure you have a life outside of work!

Words to avoid in physical exam:

• Relax, surrender, yield, let go
• Trust your body (this is the site of her trauma: she may not trust her body at all
• Tune in to your body

Be very concrete in your language: no sexual innuendos: “Take off your street clothes and put on this gown” vs. “get
undressed”

MEN’S AND WOMEN’S HEALTH SEPTEMBER 27TH 2007 – PAGE 3