“ The Culture of Silence ”

1. “The Culture of Silence ” Domestic Violence Against Women

2. INTRODUCTION • Violence against women and girls is a major health and human rights concern. Women can experience physical or mental abuse throughout their lifecycle, in infancy, childhood and/or adolescence, or during adulthood or older age. • While violence has severe health consequences for the affected, it is a social problem that warrants an immediate coordinated response from multiple sectors.

3. Violence directed at women by their intimate partners has made the “home” a frightening and dangerous place for the millions of women who are abused each year. • For many of these women, fear of social judgment and shame often prevent them from speaking out about their lives, thereby gaining support and possibly changing their relationships.

4. DEFINITION • any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life. (WHO, Feb.1996) • pattern of abusive behavior in any relationship that is used by one partner to gain or maintain power and control over another intimate partner. (US Office on Violence Against Women OVW). • Refers to any act or a series of acts committed by any person against the woman who is his wife, former wife, or against the woman whom the person has or had a sexual or dating relationship, or with whom he has a common child, or against her child whether legitimate or illegitimate, within or without the family abode, which result in or is likely to result in physical, sexual, psychological harm or suffering, or economic abuse including threats of such acts, battery, assault, coercion, harassment or arbitrary deprivation of liberty. (Republic Act of the Philippines 9262,Anti Violence Against Women and Their Children Act of 2004 Sec. 3)

5. This encompasses, inter alia, "physical, sexual and psychological violence occurring in the family and in the general community, including battering, sexual abuse of children, dowry-related violence, rape, female genital mutilation and other traditional practices harmful to women, non-spousal violence and violence related to exploitation, sexual harassment and intimidation at work, in educational institutions and elsewhere, trafficking in women, forced prostitution, and violence perpetrated or condoned by the state.“

6. History of Violence Against Women • Some historians believe that the history of violence against women is tied to the history of women being viewed as property and a gender role assigned to be subservient to men and also other women. • In early times, women are viewed to be second class citizens in the society with no power to exercise.

7. FORMS OF ABUSE • Indirect physical violence - includes destruction of objects, striking or throwing objects near the victim, or harm to pets. • Nonverbal threats may include gestures, facial expressions, and body postures. • Psychological abuse may also involve economic and/or social control.

8. PHYSICAL VIOLENCE • is the intentional use of physical force with the potential for causing injury, harm, disability, or death, for example, hitting, shoving, biting, restraint, kicking, or use of a weapon. Sexual violence and Incest • has 3 categories: • 1) use of physical force to compel a person to engage in a sexual act against his or her will, whether or not the act is completed; • 2) attempted or completed sex act involving a person who is unable to understand the nature or condition of the act, unable to decline participation, or unable to communicate unwillingness to engage in the sexual act,; and • 3) abusive sexual contact.

9. Emotional abuse • (also called psychological abuse) • can include humiliating the victim, controlling what the victim can and cannot do, withholding information from the victim, deliberately doing something to make the victim feel diminished or embarrassed, isolating the victim from friends and family, and denying the victim access to money or other basic resources. Economic abuse • the abuser has complete control over the victim's money and other economic resources. • Usually, this involves putting the victim on a strict "allowance," withholding money at will and forcing the victim to beg for the money until the abuser gives them some money. Stalking • is often included among the types of Intimate Partner Violence. Stalking generally refers to repeated behavior that causes victims to feel a high level of fear.

10. Domestic violence is a behavior learned through observation and reinforcement. It is not caused by an illness or genetics. Domestic violence is observed and reinforced not only in the family, but in society’s major institutions: Familial Social Religious Media History of Aggressive Behavior Large Power or Status Differential Isolation and Lack of Resources Controlling Relationships History of Abuse as a Child or Witnessing Parental Abuse Poorly Defined Masculinity and Identity Mental Illness such as Alcoholism or Other Drug Abuse ETIOLOGY

11. RISK FACTORS A research study in the USA addresses whether sexual and physical abuse in childhood and adolescence are risk factors for becoming a victim of violence against women as an adult. Each study found that child sexual abuse alone was a risk factor only when combined with adolescent sexual abuse. A research study in St. Petersburg, Russia The male partner's frequent alcohol consumption and seeing his father hit his mother in childhood were associated with an increased risk of violence, whereas living in a communal apartment reduced the risk of intimate partner violence.

12. The most significant sign is fear of your partner. Other signs include a partner who belittles you or tries to control you, and feelings of self-loathing, helplessness, and desperation. SIGNS and SYMPTOMS

13. YOUR INNER THOUGHTS AND FELINGS Do you: feel afraid of your partner much of the time? avoid certain topics out of fear of angering your partner? feel that you can’t do anything right for your partner? believe that you deserve to be hurt or mistreated? wonder if you’re the one who is crazy? feel emotionally numb or helpless?  Your Partner’s Belittling Behavior Does your partner: humiliate, criticize, or yell at you? treat you so badly that you’re embarrassed for your friends or family to see? ignore or put down your opinions or accomplishments? blame you for his own abusive behavior? see you as property or a sex object, rather than as a person? SIGNS OF AN ABUSIVE RELATIONSHIP

14. Your Partner’s Violent Behavior or Threats Does your partner: have a bad and unpredictable temper? hurt you, or threaten to hurt or kill you?  threaten to take your children away or harm them? threaten to commit suicide if you leave? force you to have sex? destroy your belongings? Your Partner’s Controlling Behavior Does your partner: act excessively jealous and possessive? control where you go or what you do? keep you from seeing your friends or family? limit your access to money, the phone, or the car? constantly check up on you?

15. POWER and CONTROL of the ABUSER • Dominance — Abusive individuals need to feel in charge of the relationship. • Humiliation — An abuser will do everything he can to make you feel bad about yourself, or defective in some way. • Isolation — In order to increase your dependence on him, an abusive partner will cut you off from the outside world. • Threats— Abusers commonly use threats to keep their victims from leaving or to scare them into dropping charges. Intimidation — Your abuser may use a variety of intimation tactics designed to scare you into submission. Denial and blame — Abusers are very good at making excuses for the inexcusable. They will blame their abusive and violent behavior on a bad childhood, a bad day, and even on the victims of their abuse. Your abuser may minimize the abuse or deny that it occurred.

16. THE CYCLE OF VIOLENCE Abuse — The abuser lashes out with aggressive or violent behavior. Guilt — After the abusive episode, the abuser feels guilt, but not over what he's done to the victim. Rationalization or excuses — The abuser rationalizes what he's done. "Normal" behavior — The abuser does everything he can to regain control and keep the victim in the relationship. He may act as if nothing has happened, or he may turn on the charm. Fantasy and planning— The abuser begins to fantasize about abusing his victim again, spending a lot of time thinking about what she's done wrong and how he'll make her pay. Set-up — The abuser sets up the victim and puts his plan in motion, creating a situation where he can justify abusing her.

17. Domestic violence warning signs • Frequent injuries, with the excuse of “accidents” • Frequent and sudden absences from work or school • Frequent, harassing phone calls from the partner • Fear of the partner, references to the partner's anger • Personality changes (e.g. an outgoing woman becomes withdrawn) • Excessive fear of conflict • Submissive behavior, lack of assertiveness • Isolation from friends and family • Insufficient resources to live (money, credit cards, car) • Depression, crying, low self-esteem

18. MEDICAL/ SURGIAL TREATMENT Treatment for victims of violence in women may vary depending on the extent of damages done to the women either physical, emotional or psychological damages or the combination of the three. • Physical damages may vary from small bruises to fractures to chronic physical disabilities. • Initially, pain and wounds may temporarily be treated with pain and wound medications. • Usually victims of abuse uses topical make up to cover up small bruises on exposed areas usually on face and arms. • For victims who acquired STDs a consultation to a health expert should be done. • Talk to your doctor, who can treat any medical problem, provide support and make referrals. Call an emergency shelter and ask about counseling and support groups for you and your children. Nurses, social workers and other health care professionals can also help you.

19. NURSING CARE MANAGEMENT • Whenever abuse, maltreated or neglect is suspected, the health care worker’s concern should be the safety and welfare of the patient. • Treatment focuses on the consequences of the abuse, violence, or neglect and on prevention of further injury. • Multidisciplinary approach should be used. The health care team should work collaboratively. • If in immediate danger, the patient should be separated from the abusing or neglecting person whenever is possible. • Nurses must be mindful that competent patient has the right to accept or refuse the help offered to them. Some patient will insist on remaining in the home environment. The decision of the patient should be respected. • Mandatory reporting laws require health workers to report suspected abuse to an official agency, usually Adult (or child) Protective Services. All that is required for reporting is the suspicion of abuse. • Subsequent home visits should be part of gathering information about the patient in the home environment.

21. ASSESSMENT • During the physical examination, look for injuries on many areas of the body. Note any bruises, burns, or wounds shaped like objects such as teeth, hands, belts, or cigarette tips. Be alert for puncture wounds, fractures and dislocations, and scars on the vulva or rectum. Be aware that the woman may wear a glove or sock to conceal a scalded hand or foot. Be alert to any pattern of non–life threatening injuries at various points in the healing process. • Record visual evidence via still or video camera. Be sure to include full-body views as well as individual views of each injury with an object provided for size reference (eg, ruler, coin) • Use open, nonjudgmental questions that neither imply blame nor ask why • Recognize potential evidence; collect, preserve, and maintain chain of custody • Explain all therapeutic protocols, including evidence collection, to client

22. DIAGNOSIS Nurses and other healthcare professionals should follow a regular procedure with all clients: • Learn to recognize potential victims and question them directly about abuse • Implement your agency's domestic violence protocol if you are suspicious • Triage for immediate medical needs • If medical needs are not immediate, take a client history in a private room • If medical needs are immediate and a disruptive or dangerous partner is present, call security and/or local law enforcement • Contact your victim's advocacy representative and offer services to client • Every healthcare facility serving women, children, and older adults needs to screen for potential domestic violence.

23. When assessment and examination are complete, review any therapeutic protocols with the client and provide a supportive and encouraging environment in which the client can seek help and get support. Be prepared to: Provide appropriate diagnostic and therapeutic interventions in collaboration with other providers, if needed Provide verbal and written information about domestic violence and legal options Provide a listing of relevant community resources Make any necessary referrals Initiate mandatory reporting procedures when required Once the women is identified as being a risk for violence, work with her to develop an individualized plan provide to prevent future violence. As a prevention strategy, include community health nurse visit to high risk families and community- wide media campaigns to enhance public awareness of the problem Explain stress management strategies, especially effective coping to help client avoid violence. Make a protocol together with local enforcement agencies and women’s safety groups to protect the woman identified with a violent relationship. PLANNING INTERVENTION

24. Domestic Violence in Women, starts with screams…BUT must NEVER end in silence….

25. REFERENCES: Journal Articles: • Nayberi, Leaky.2007.Breaking the Silence. Journal of Health and Home. Philippine Publishing House. Caloocan City, Philippines. Books: • Black, Joyce and Hawks, Jane Hokanson.2005. Medical- Surgical Nursing: Clinical Management for Positive Outcomes. 7th Edition. Vol.1. Elsivier Inc., Philadelphia, USA. • Kesselman, A., McNair, L., and Schniedewind, N., 1999. Women: Images and Realities. A Multicultural Anthology. 2nd Edition. Mayfield Publishing Company. Mountain View, California, USA. • Lips, Hillary. 2003. A new Psychology of Women: Gender, Culture and Ethnicity. 2nd Edition. McGraw- Hill Companies. New Yor, USA. • Smiltzer, S. and Bare, B., 2004. Medical Surgical Nursing. Vol. 2 Lippincot Comapany. USA Web Articles: • www.athealth.com/Consumer/disorders/DomViolFacts.html • http://en.wikipedia.org/wiki/Domestic_violence#Violence_against_women • http://www.who.int/mediacentre/factsheets/fs239/en/index.html • http://www.helpguide.org/mental/domestic_violence_abuse_types_signs_causes_effects.htm • http://www.nursingceu.com/courses/201/index_ccare.html

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