Setting standards for the medical care of victims of gender violence

Growing awareness leads to legislation

In Germany, public awareness of gender-specific violence was given a boost in the 1970s as a result of the emergence of the women’s movement, which opened up discussion of rape and sexual violence. The subse­quent creation of women’s refuges, help lines and pro­grammes to protect and support girls made the topic an integral part of political discourse. In the 1980s, sexual abuse within families was systematically defined as a crime (Straftaten gegen sexuelle Selbstbestimmung) and was followed by the foundation of help facilities for victims of sexual abuse. Through this, domestic violence against women and children was recognised and received increased public attention. To combat gender-specific violence, since 1999 the government has developed National Action Plans (NAPs). The core of the first NAP was legislation (such as the Protection against Violence Act (Gesetz zur Verbes­serung des zivilrechtlichen Schutzes bei Gewalttaten und Nachstellungen, Gewalt­schutz­gesetz – GwschG) to ramp up the criminal prosecution of violence – especially domestic violence. Federal programmes are interconnected with initiatives at state (Land) level and with projects by non-governmental organisations. Several initiatives at Land level aim to raise the awareness of the public in general and of experts in this field in particular.

In September 2007, the federal government launched the Second Action Plan of the Federal Government to Combat Violence against Women in order to respond to the current challenges regarding the protection of women affected by violence and their children. A key focus of the plan is the healthcare sector. As part of this action plan, and following positive experience in the clinical area, the Federal Ministry for Family Affairs, Senior Citizens, Women and Youth launched a pilot project to ensure that women victims are given the right assistance.

Creating an intervention model

The Medizinische Intervention gegen Gewalt (Medical Intervention against Violence – MIGG) project developed unified standards for the treatment of women victims of violence in emergency rooms and specialist outpatient departments, and identified the main warning signs – known as red flags – that may indicate domestic violence and merit attention from health personnel. It also considered the needs of specific victim groups such as migrant women and women with a disability.

The main aim of the three-year project, which was piloted in five locations, was to introduce and test an intervention programme to train and raise the awareness of physicians in their own practices. It also tested the all-important cooperation and networking between out­patient departments and regional emergency violence support centres.

MIGG created a medical intervention model to improve the healthcare treatment of women victims of domestic violence and to increase healthcare professionals’ awareness of the issue. The project helped doctors to identify and address the consequences of violence, and to document evidence for use in court.

It did this through conducting an intense exchange with universities and healthcare units, offering doctors support in documenting injuries for use in a court of law, giving specialist advice, distributing posters and information for patients to support health education, training and information events, and setting up an internet platform.

International standards

The intervention model was based on international standards for health units in different medical sectors, and was tested with several self-employed medical practitioners in five regions of Germany, including both rural and urban areas in Berlin, Düsseldorf, Kiel, Munich and Ennepe-Ruhr-Kreis.

The project trained 136 doctors (77 female and 60 male with various qualifications, including internists and gynaecologists in outpatient departments) in how to approach women victims of violence, and in where to find information. It provided information and training materials on documentation, communication, the law and regional networks working with women victims of violence (both NGOs and the judiciary system). It presented and implemented standards for practice. The intervention standards are an evidence-based plan of action for the medical care of women victims of domestic violence. During implementation, doctors were supported by the pilot project partners. The training was very successful, as testified by interviews with both trainers and trainees.

The project also involved organisations and authorities working with women victims of violence, in order to improve networking and enable them to integrate healthcare in their overall intervention. The best outcome in this regard was in Berlin, where networking has continued since the end of the pilot project with additional finance from the Berlin govern­ment. In general, the pilot project produced multiplier effects in all five locations.

Relevance, sustainability, impact and effectiveness

Given that the healthcare sector plays such an important role in fighting domestic violence, the MIGG pilot project is of particular relevance because it identifies a synergic way in which medical intervention to victims of violence can be carried out. The project has had a wide impact by creating a model that can be implemented nationwide. Its activities in five different areas proved its effectiveness in building the capacity of doctors, medical associations and local networks of organisations working with victims of domestic violence.

MIGG spent public funds well as the practice increased the efficiency of the public health sector and professionals in tackling these issues. The practice was based on a clear, appropriate and comprehensive definition of domestic violence, which helped health professionals to increase their capacity to provide comprehensive and tailored information and support to the victims. It is based on a multiagency approach involving many different public and private organisations dealing with domestic violence.

The project was carried out by the Gesellschaft für Sozialwissenschaftliche Frauen- und Genderforschung e.V. (GSF e.V.), Signal e.V. (Berlin), GESINE-Netzwerk (Ennepe-Ruhr-Kreis) and the Institute of Legal Medicine, University of Düsseldorf (for Kiel and Munich) in cooperation with the local Institutes of forensic fedicine at the university hospitals. It was funded under the Second Action Plan of the Federal Government to Combat Violence against Women.

Multiagency cooperation is important

The pilot project was evaluated by Gesellschaft für Sozialwissenschaftliche Frauen- und Genderforschung e.V. (GSF e.V.) which interviewed trainers and trainees during the project. Other methods of evaluation were questionnaires for trainers and trainees, participatory monitoring of the training sessions, interviews with board members and continuous counsel­ling of the project managers. The evaluators included social scientists, medical doctors and self-employed practitioners. An additional result of the evaluation is an implementation guide, including practical examples and recommendations, for those who want to implement the model.

The project’s success resulted from the partners’ great experience and competence in the field. The GESINE Network is the WAVE (Women Against Violence Europe)[1] focal point on health in Germany, and since 2004 has been working on intervention models for improving the treatment of women victims of violence, and helping health professionals to better recognise violence and treat it adequately, including considering psychological aspects. It also benefited from a multiagency approach with strong and committed networking involving anti-violence associations, medical organisations and associations of general practitioners.

It identified a systematic routine screening procedure to detect domestic violence victims in emergency rooms and other health departments, supported by comprehensive tailored information and support. Its federal government finance allowed the partners to dedicate to it the time and resources needed to obtain good results.

Nevertheless it did find that doctors are a difficult target group to work with, because they have their own standards and procedures, so at the outset it was quite hard to convince them that domestic violence and the treatment of victims is important and that they had to improve the quality of their approach. In overcoming this obstacle, and introducing new standards and procedures, the commitment of medical associations was an important tool, but it was not enough: personal contact with all the doctors involved proved more effective.

At the moment, the model is still under way in Berlin and Ennepe-Ruhr-Kreis, financially supported by the governments of Berlin and Nordrhein-Westfalen. In Munich, Kiel and Düsseldorf the outpatient services at the university institutes of legal medicine are working with women victims of domestic violence, also financed by the respective Land governments. Extending the model country-wide will depend on gaining the support of the remaining Länder.

The MIGG pilot shows that multiagency cooperation is essential in achieving an impact on the whole system. Support from medical associations is quite important, but it is also essential to build personal relationships with the doctors involved. Having good expert trainers on board is crucial in attracting health professionals to take part. Finally, in moving from a pilot project to a stable activity, extra financial support is needed in order to increase the number of practitioners that can be trained, and to support networking.

[1] http://www.wave-network.org/