Amy Buller established an educational foundation at Cumberland Lodge in 1947 to debate the ‘moral and spiritual issues of the day’. At that time, the issue of violence against women was not on the public policy agenda. In fact the first piece of legislation to address ‘violence in marriage’ was not introduced until nearly thirty years later. For Cumberland Lodge to host a two day conference (6-7 February, 2017) on violence against women as a determinant of health shows just how far society has come in recognising and seeking to respond to this important issue.
Around 60 delegates attended the conference from a range of different backgrounds. They agreed on the scale of violence against women. They also agreed that it is rooted in gender inequality. Yet how to accurately measure the prevalence of violence against women in its many different forms and over the life course of girls and women was recognised as an ongoing challenge. It was also recognised that in order to prevent violence against women from happening, gender inequality has to be addressed.
In her keynote speech, Professor Dame Sally Davies (Chief Medical Officer for England) observed how violence against women as a determinant of health was not an issue that had been addressed by any of her (all male) predecessors.
Framing violence against women as an equality and human rights issue is often contested. Debating the health response to violence against women from a common understanding proved refreshing for delegates.
Whilst acknowledging that health is just one part of the societal response required to prevent violence and intervene early, delegates were made acutely aware that almost a third of victims come into contact with health professionals. They welcomed the space that the conference provided to reflect on what more the health profession can do.
A wider context
Much debate centred on the need to address violence against women in all its forms, moving beyond a narrow focus on domestic abuse. Discussion about this led to interesting conversations about culture and the need to avoid ‘othering’ women who experience forms of violence that include forced marriage and female genital mutilation. Whilst the forms and contexts may be different, the meaning is the same. At the same time, there is a no linear relationship between different forms of violence against women and context. Connections exist across all forms - they ‘weave in and out’ of each other, as well as across women’s life course.
Previous experiences shape how women experience violence. This means that there is a cumulative impact on both physical and emotional health.
Professor Liz Kelly highlighted how women, whatever political context they are navigating, resist cultures that support violence against them. In this respect violence against women is simultaneously local and global.
A public health approach
Another topic of debate was how, despite the legal protections that abused girls and women are now afforded, violence against women is still not recognised in the ‘medical’ world. Health professionals may treat its ‘symptoms’ but do not delve deeper to explore their cause.
Delegates agreed that questions about abuse were ‘too rarely asked’. At the same time they asked themselves ‘do we really want to know, hear and understand?’.
Identification of abuse emerged as an issue that needs to be addressed. Although there is training on some forms of violence against women in some under and post graduate medical courses, the issue is not given the attention it deserves. There is also a lack of focus on helping trainee medics to develop the skills required to ask questions and to practice doing so. Again, in the words of a delegate ‘it comes down to difficult interactions and judgments’.
Intervention was linked to concerns about patient confidentiality and not breaking trust if a patient discloses abuse but does not want to report it. Patient choice was recognised as important since abuse is underpinned by the taking away of power.
There was agreement that responses need to be grounded in belief. They need to be empowering in approach and choices need to be made explicit. Disclosure should also be validated.
Delegates heard from women who have experienced violence and who reflected on the significance of language and the impact that labels such as ‘victim’ can have on them. Another area highlighted as significant was the emotional impact that responding to abuse has on professionals, in particular those who may have experienced violence themselves.
Barriers to asking were also linked to the existence of and knowledge about support pathways. The challenging economic context was discussed in which services have to do more with either the same or less resource. Referral pathways were observed to have become more complex as a consequence.
Delegates expressed concern about linking access to services to levels of ‘risk’ meaning that women who are unable to reach high thresholds may be unable to access support. Simultaneously it was recognised that the cost of leaving violence against women unaddressed results in greater costs to the health service in the longer term.
The presence of colleagues from the police service and their sharing of how they approach violence against women provided valuable learning. Delegates also learned from each other through sharing their experiences, thoughts and ideas.
Feedback from delegates following workshop discussions was that they were in ‘next steps mode’ – ready and motivated to take the learning back to their workplaces and to start putting it into action. A number of solutions were proposed – too numerous to list here – but including the need:
- For strong leadership to make violence against women a ‘medical issue’ and even a medical specialism;
- To make violence against women (in all its forms) a mandatory part of medical training and ongoing professional development;
- To routinely ask about violence and to be professionally curious;
- To work in partnership with other services in order to ensure holistic and coordinated responses;
- To build the confidence of health professionals through communicating outcomes back to the person who made the referral;
- To ensure that funding is available for specialist services in the third sector that health professionals can refer patients on to; and
- For longitudinal research over the life course of women to truly understand the impact of abuse in both childhood and adulthood; providing the economic and ethical evidence that will help commissioners of health services ‘make the case’.