Emergency Doctors without boundaries: we need to talk about violence against women

Emergency Doctors without boundaries: we need to talk about violence against women

800 451 Kat Evans


Author: Dr Lucy Hindle – Emergency Physician – Gauteng, South Africa

Co-author: Katy Hindle – lawyer with a special interest in gender and health

Edited by: Dr Kat Evans – Emergency Physician – Cape Town, South Africa

What is intimate partner violence? 


IPV is violence perpetrated by an intimate partner (so a boyfriend/husband/ex).

Most commonly, it includes:

  • Physical violence eg: slapping, punching, kicking, assault with a weapon,
  • Sexual violence eg: rape, coercion, or
  • Psychological violence eg: intimidation, stalking, withholding money or preventing visits with friends or family.
  • But it can also include other forms of violence.

Although both men & women can be victims or perpetrators of IPV, women make up the majority of IPV victims.


Is IPV the same as domestic violence?


The terms IPV & domestic violence are often used interchangeably & South African law refers to domestic violence. There are some important differences though. Domestic violence is violence that happens in a house (as the word ‘domestic’ might imply) & it can occur between any of the people living in the  house, they need not be related or in a relationship (so for example a brother assaulting his sister).


By contrast, intimate partner violence is violence perpetrated by an intimate partner & can occur anywhere (in a bar, outdoors etc.). IPV may also occur in a house but this type of violence isn’t characterized by where the violence takes place & it’s not necessary for the people involved to live together. An example of IPV might be where an ex-boyfriend attacks his previous partner at a night club.


How common is IPV?


IPV is a huge problem around the world. Estimates by the WHO put lifetime prevalence (the likelihood that someone might experience IPV during their lifetime) at 1 in 3 women. In South Africa the stats are similar but we have the highest rate of women being killed by intimate partners in the world. High profile cases like Oscar PistoriusChristopher Panayiotou tend to get lots of media coverage but on average, a woman is killed by an intimate partner every 8 hours in South Africa. If you are a woman in South Africa, you are more at risk of being killed by a current or previous partner than by a stranger.


The health issues faced by victims of IPV go beyond just the effects of trauma – women who are abused have increased rates of chronic disease, psychiatric issues & sexually transmitted disease including HIV. IPV also has far reaching consequences on economic development, because women in abusive relationships often miss work or are prevented from working due to injury.


Okay.. So obviously this is bad- but how is this an emergency medicine issue?


All of us in emergency medicine are managing and treating women who’ve been abused, we might just not be recognizing it! We see people at their most vulnerable & often, we are the only interaction with healthcare that victims of IPV have. If we see women who have been abused & don’t identify IPV as the problem or worse, identify it but don’t ask questions or go any further, we are contributing to the culture of silence & shame and to the secondary victimization which so many women face.


Imagine you had been abused & told your doctor what happened and who was responsible for it. If your doctor treats the injury & sends you on your way, that suggests to you that abuse is normal, accepted & that there is nothing that can be done to change the situation.


But other, more supportive situations are equally possible. Our role in EM is to save lives – & IPV is a life-threatening problem just like many others we have been trained to respond to.


So what do I do? Who should I even be asking? 


Although asking everyone we suspect might have been the victim of IPV would be ideal, it isn’t always practical in our settings.


We should definitely ask:

Victims of assault/injuries (even if another explanation is given)


Pregnant women: pregnant women are at a higher risk of more violent IPV & pregnancy might be the only time women will come into contact with healthcare providers.


Those with chronic pain (headaches, back pain)


Those with depression or anxiety


Women who are HIV positive: women who are abused may be less likely to be able to negotiate condom use, may have been raped or may be abused because they are HIV positive.


The more we ask patients about IPV, the more routine it becomes & the more we can change the culture of shame and silence that allows it to continue unchecked in our communities.


How do I ask? Won’t my patients be offended?


There’s good evidence that women would like to be asked about IPV & are not offended by sensitive questioning.


A “partner violence screen” was developed specifically for Emergency Departments. It consists of 3 questions, which should be asked in a private place & outside earshot of a partner!

Have you been hit, kicked, punched, or otherwise hurt by someone within the past year? If so, by whom?

Do you feel safe in your current relationship?

Is there a partner from a previous relationship who is making you feel unsafe now?


Okay.. So then what? I feel like there’s nothing I can do so I would rather not ask!


Feeling a little helpless is common – but think about IPV as a chronic illness. You don’t jump in to cure hypertension on a first visit but you still screen, counsel & refer.


If you diagnose IPV there are some simple steps that might make a big difference. For example:


Assess immediate threats to safety, including to any children:

Is there a gun in the house?

Have there been any threats to kill?

Have there been previous serious attempts?

Do you suspect any child abuse? Remember that legally this needs to be reported.


If anything seems immediately life threatening, consider referral to the police, a social worker or to a local place of safety & if your patient agrees, you may want to keep them in hospital until a plan is in place.


NB: The period around when a woman leaves a relationship is high risk for homicide & severe violence so women need to plan this carefully. Only they will know & should decide the best thing for themselves & their children & your role is simply to support this.


Refer to other resources


Legal resources

  • Protection order
    • This is a legal document that can be obtained at a magistrate’s court & details what the alleged abuser may not do.
    • You do not need legal representation to apply for a protection order & an interim protection order is usually issued quickly to protect a person while they are waiting for the final protection order to be issued.
    • For example, it might specify that an alleged abuser may not enter a shared property, visit the applicant’s place of work or commit any further acts of violence.
    • If the alleged abuser contravenes the specifics of the protection order, they can be arrested.
    • A protection order is not the same as laying a criminal charge. However, if there was a crime of assault or rape a criminal case can be opened by the police.

Click here for a great guide by the women’s legal center on the domestic violence act and the process involved in applying for a protection order. http://www.wlce.co.za/images/domesticviolenceguide.pdf


The stop gender violence helpline is a toll free, 24 hour helpline & can provide advice, counseling & information.

Other related reading:

 About the author:

Lucy Profile

Dr Lucy Hindle

Emergency Physician – Gauteng, South Africa

Interests: systems improvements, woman and child health & travel.

Kat Evans

Emergency Medicine Physician in Cape Town, South Africa. Looking for solutions to our unique EM challenges with a quadruple burden of disease.

All stories by:Kat Evans

Kat Evans

Emergency Medicine Physician in Cape Town, South Africa. Looking for solutions to our unique EM challenges with a quadruple burden of disease.

All stories by:Kat Evans