LETTING THE LIGHT IN:
UNIVERSAL SCREENING FOR WOMAN ABUSE IN A
NORTHERN HEALTH CARE SETTING
by
Paula Hunter
BSocSc, University of Ottawa, 1992

PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SOCIAL WORK

© Paula Hunter, 2003

THE UNIVERSITY OF NORTHERN BRITISH COLUMBIA
March 2003

All rights reserved. This work may not be
reproduced in whole or in part, by photocopy
or other means, without the permission of the author.

UNIVERSITY OF NORTHERN
BRITISH COLUMBIA

UBRARY
Prrnce George, BC

ABSTRACT
Given that substantial numbers of abused women seek health care services and given the
negative impact abuse has on women, children and communities at large, the health care sector
has a vital role to play in addressing violence against women. However, due to a combination of
personal, institutional and ideological factors, the needs of abused women are often overlooked
in the health care encounter. This is troubling because the hospital emergency room represents a
significant point of entry for abused women to receive treatment, support and safety. For those
living in northern, rural and remote communities, the hospital may be the only source of
assistance available to women experiencing violence. This case study critically explores the
implications of adopting a health care policy known as "universal screening" for use in a
northern, rural or remote health care setting. It is argued that with appropriate training and
education, health care providers can use the screening process to go beyond simply inquiring
about abuse and treating the physical symptoms to paving the way to women's empowerment.
The main goals of screening from an empowerment perspective are listening with empathy;
providing support and validation; offering appropriate treatment, information and referrals; and
reassuring women that the violence is not their fault. Most notably, this project asserts that
developing a critical consciousness about the complex interplay between the personal, social
and political aspects of woman abuse is a necessary component of empowerment practice. With
this knowledge, rather than feeling that they need to fix the problem, health care providers will
recognize that women are the best judges of their own circumstances.

11

TABLE OF CONTENTS
Abstract

11

Table of Contents

lll

Acknowledgments

v
1

Introduction
Statement of the Problem
MSW Case Study Description and Rationale
Key Concepts

4
9

Chapter Two

Method of Analysis: Critical Thinking
My Standpoint: Multi-Focussed Feminist Lens

15
16

Chapter Three

Violence Against Women in Northern, Rural and Remote
Communities
The Key to Control: Isolation
Barriers to Escaping Violence
Institutional and Structural Barriers
Social/Cultural Isolation

Chapter One

Chapter Four

Chapter Five

Women, Violence and Health
The Many Costs of Woman Abuse
Health Consequences of Woman Abuse
A Call for Action
Barriers to Discussing the Issues
Physician/Nurse Barriers
Patient Barriers
Case Study Analysis: From Oppression
to Empowerment
Secondary Oppression: The Isolation Continues
Medicine & Patriarchy
The Medical Model
The Medical Model and Interventions with Victims
Universal Screening: Setting the Stage
For Empowerment

lll

2

21

22
23
24
25

30
30
31
33
34
34

38
45

46

49
51
52
56

Chapter Six

Empowerment Approach to Helping Victims
In the Health Care Encounter
EmpowermentDefined
Developing a Critical Consciousness
Education about the Dynamics of Abuse and Health
Consequences
The Primary Goals of Universal Screening
Step 1: Routine Screening and Identification
Step 2: Recognizing Symptoms and Validation
Step 3: Recording Victimization
Step 4: Referring Patients

62
63
64
70
72
73

Chapter Seven

Implications for Social Work Practice
Discipline-Jumping

75
76

Chapter Eight

Evaluation of the Policy and Future Research Recommendations
Potential Challenges of Universal Screening
Future Research

78
78
82

Chapter Nine

Summary and Concluding Comments

84

58
58
60

Endnotes

86

References

88

IV

ACKNOWLEDGMENTS
I would like to acknowledge and thank those people who played an important role in the
completion of this project. First and foremost, I want to thank my project supervisor, Dr. Si
Transken, whose guidance, encouragement and creative inspiration was a major catalyst in my
finishing this project. I am also grateful to Dr. Kwong-leung Tang for the feedback he gave me
and the insights he brought to my project. I want also to thank Dr. Robert Budde for kindly
agreeing to participate as a member of my committee and for his input. In addition, I want to
thank the members of the "First Friday Thesis Support Group" for their knowledge, assistance
and motivation over the past year. Of course, without the enduring support and understanding of
my family and friends, I would not have been able to finish this project or complete my
Master's degree . I am enormously grateful to Daryl, Lane and Claire for giving me the space
and time I needed to carry out my work. I also want to express my appreciation to Maria
Lamparski and Leona Leiski, both of whom lovingly and reliably cared for my children over the
course of my studies at UNBC.

v

CHAPTER ONE
Introduction
The feminist movement of the 1970s was instrumental in raising public awareness about
the subject of violence against women in relationships (Bograd, 1988). However, despite years
of hard work and public awareness campaigns, violence against women continues to be a
pervasive social problem (hooks, 1984). In 1996, the 49th World Health Assembly declared that
violence against women is a leading worldwide public health concern and violation of basic
human rights. It announced that gender violence is a serious social problem, affecting women of
all geographic locations, classes, cultures and age groups (World Bank, 1997). The types of
violence that girls and women are subjected to around the world today include sexual assault,
female infanticide, forced prostitution, forced marriage, genital mutilation and slavery.
However, the most pervasive form of gender violence is the abuse women endure at the hands
of an intimate partner (Panos Institute, 1997).
According to a recent worldwide study of domestic violence, up to 50% of women
around the globe have been physically assaulted by an intimate male partner (Heise, Ellsberg, &
Gottemoeller, 1999). In the United States, for example, a woman is assaulted every 15 seconds,
and most often the perpetrator is her husband. In Canada, studies show that 29% of women ever
married have been sexually or physically assaulted by a current or former male partner since the
age of 16 (Rodgers, 1994 ). In countries such as Egypt, Bangladesh, Cambodia, Mexico and
Zimbabwe, wife-beating is often justified as a husband's right to "correct" his wife (Heise et al.,
1999). Each year in the United Kingdom, one woman in ten is severely beaten by an intimate
partner (Panos Institute, 1997). In many cases, the abuse is so severe it costs women their lives.
Studies conducted in Canada, Brazil, Russia and Israel demonstrate that women are more likely

to be killed by an intimate partner than by a stranger (Panos Institute, 1997). A recent Canadian
report revealed that over half (52%) of all female homicide victims in 2001 were killed by an
individual with whom they had an intimate relationship at one time, either through marriage or
dating (Statistics Canada, 2002). While these figures may be troubling, they do not adequately
represent the extent of the problem because many incidents of abuse go unreported . Indeed,
many victims do not tell anyone about the violence or ask for help (Heise et al., 1999).
Statement of the Problem
For those who do reach out for help, there are transition houses, crisis lines and other
interventions now available to help victims of violence (Duffy & Momirov , 1997). Other
services available to abused women today include professional sources of support such as
police, lawyers, physicians, counsellors, and other less formal sources of help such as support
groups and the clergy (Gordon, 1996). Some studies reveal, however, that not all of these
sources of assistance are perceived as very useful or helpful to abused women (Gordon, 1996).
The health care system, for example, has come under increasing scrutiny for not adequately
addressing issues of violence with patients, despite the fact that abused women use a
disproportionate share of health care services (Koss, 1994). This criticism is based largely on
studies that reveal that only the most serious cases of physical violence are recognized by
physicians, while the social and emotional aspects are virtually ignored (Stark, Flitcraft, &
Frazier, 1979; Kurz & Stark, 1988; Warshaw, 1993; Varcoe, 1997). When violence is detected,
studies show that women often feel that they have been treated in an insensitive and even hostile
manner (Yam, 2000; McCauley, Yurk, Jenckes, & Ford, 1998; Varcoe, 1997). Although some
women report feeling validated, respected and supported by their provider (Gerbert,
Abercrombie, Caspers, Love, & Bronstone, 1999; Yam, 2000; Varcoe, 1997), some leave the

2

health care encounter feeling dismissed, judged and blamed for the violence (Yam, 2000;
McCauley et al., 1998).
Fortunately, in recent years efforts have been made by the health care sector to respond
more effectively to the needs of abused patients. For example, nurses and physicians have been
urged by their professional organizations to adopt formal protocols and policies that effectively
and routinely inquire about intimate abuse (Hotch, Grunfeld, Mackay, & Cowan, 1996). The
American Medical Association ( 1992) declares: "Due to the prevalence and medical
consequences of domestic violence, physicians should routinely inquire about abuse as part of
the medical history" (as cited in Grunfeld, 1997, p. 365). The general goals of screening are to
ask all women about abuse, regardless of injury; to identify victims; to validate that the violence
is not deserved; to document the violence and to refer patients to appropriate sources for help
(Hotch, Grunfeld, Mackay, & Cowan, 1995). Similarly, many Canadian organizations, including
the Canadian Medical Association of Emergency Physicians, the College of Family Physicians
of Canada and the Canadian Association of Social Workers, advocate for screening in all
emergency departments (Grunfeld, 1997). In Britain, official recommendations regarding
routine screening have yet to be implemented, but there appears to be considerable support for
routine screening from both practitioners and patients (Howe1, Crilly & Fairhurst, 2002).
Despite this increased awareness about the prevalence of woman abuse and the
importance of using screening protocols, many physicians continue neglecting to routinely
screen their patients (Morrison, Allan, & Grunfeld, 2000). In fact, few hospitals or primary care
facilities in urban or rural Canada have a formal universal screening policy in place (Hotch,
Grunfeld, Mackay, & Ritch, 1996). This is troubling, because the costs of not asking are high,
particularly for victims who live in isolated communities where access to support is often

3

severely limited (Greenard-Smith, 2002; Derk & Reece, 1989). When violence against women
is not acknowledged, opportunities for women to receive appropriate treatment, support,
information and referrals are missed, and the violence will likely continue and escalate. Not
only will the emotional, physical and spiritual well-being of a woman living in an abusive
relationship deteriorate, her use of health care services will eventually increase (Ingram 1994;
Gordon, 1996; Koss, 1994). Besides letting health care providers effectively identify and treat
the physical injuries and emotional trauma that women endure, studies suggest that universal
screening gives health care providers the opportunity to pave the way to women's empowerment
(Hadley, 1992; Archer, 1994; Ingram, 1996). Even if women choose not to discuss the abuse
with their health care provider, studies indicate that being treated with respect and being
validated can help women look at their situation differently and even plant the seed for moving
them toward safety (Gerbert, Abercrombie, et al. , 1999).
MSW Case Study: Description and Rationale
"From my experience here in the emergency department, I know that abuse and violence
at home is a problem for many women. Is it a problem for you in any way?" (Hotch et
al. , 1995,p. 11 )
The idea that health care interventions can be empowering for abused women has been
discussed in the literature (Campbell, 1998; Warshaw, 1994; Hadley, 1992; Ingram, 1994;
Abbott & Williamson, 1999; Archer, 1994; Gerbert, Abercrombie, et al. , 1999; Transken, 1995,
2000). However, very little has been written about this topic from a northern health care
perspective. This absence of research is not surprising given that the subject of woman abuse in
rural locations itself receives very little attention (Websdale, 1998). However, what is known
about "domestic violence" is that it is a social phenomenon that is clearly not confined to a

4

specific geographic region. Despite popular misconceptions about rural areas being immune
from these problems, some studies suggest that the prevalence and/or duration of woman abuse
is higher in rural communities than it is in urban settings (Johnson & Elliott, 1995; GreenardSrnith, 2002; Rodrigues, 2003). Furthermore, various socio-economic and cultural factors
operate in rural communities that make women more vulnerable to the effects of abuse and
·hinder their ability to access supports (Edelson & Frank, 1991; Websdale, 1998; GreenardSrnith, 2002; Rodrigues, 2003). Given that the hospital may be one of the only outside contacts
that abused women can rely on for support and information in a rural community, it is critical
that health care providers take a proactive role in addressing violence in the lives of their
patients (Abbott, 1997). While the idea that universal screening offers practitioners a way to
break the cycle of violence has been raised in the literature, few articles have explored the
implications of using this policy in rural or northern settings. It was this gap in the research that
inspired me to investigate this topic further and to make it the subject of my Master of Social
Work case study.
. The purpose of this case study is to provide a critical analysis of a universal screening
policy for use by physicians and nurses with abused women residing in northern, rural or remote
communities. Furthermore, this paper will discuss the merits of adopting a formal screening
policy, based on empowerment principles, for use with abused women in these communities. As
such, this paper begins with a discussion about woman abuse from a northern, rural and remote
perspective. After this, I address the issues pertaining to abused women's encounters with the
health care system. Using a feminist lens of analysis, I argue that unsatisfactory helping by the
health care community stems not from a desire to intentionally ignore the needs of women, but
from a number of factors including personal attitudes and institutional constraints. However, a

5

major contributing factor preventing health care providers from being able to provide quality
care to abused women appears to be embedded in broader ideological conditions. To be more
specific, the negative attitudes and stereotypes that prevail about abused women in a patriarchal
society are often mirrored in the institutions that abused women most often turn to in time of
need: the criminal justice, legal, social welfare and medical systems (Duffy & Momirov, 1997).
As such, through various practices and policies (or, as in this case, lack thereof) social
institutions unwittingly tolerate and foster male violence and oppression (Duffy & Momirov,
1997). With regard to the medical system, this means that instead of acting as allies in the fight
against violence against women, the medical establishment (and other agencies) unintentionally
become passive collaborators in women's victimization (Transken, 1995). While it is true that
all women in a patriarchal society are oppressed, it is also clear that oppression of all women is
not the same (Lee, 2001). As I will demonstrate, this is the case for women of colour, immigrant
women, First Nations women, poor women and rural women, who often face additional
obstacles when they encounter the health care system.
Following this discussion, I will explore the merits of adopting a formal screening
policy, based on empowerment principles, for use with abused women in a northern setting.
"Empowerment" is a term often loosely used, and it may have different meanings for different
people. From an anti-oppressive social work point of view, it refers to "a process through which
people reduce their alienation and sense of powerlessness and gain greater control over all
aspects of their lives and their .social environment" (Mullaly, 2002, p. 179). An empowerment
framework is an integrative, holistic approach whose aim is to encourage social workers (and I
include all "helpers" in this definition) to develop knowledge in order "to help people to
empower themselves in the personal, interpersonal and political levels of life" (Lee, 2001, p.

6

24). This paper will show that empowerment practice represents a shift in ideology: from an
individual level of analysis of social problems to one that understands that root causes of social
problems such as violence are based on the way society is structured (Mullaly, 1997, 2002).
With respect to health care, working from empowerment principles means moving away from a
narrowly defined medical paradigm (which tends to pathologize victims and blame them for
their circumstances) to an empowerment-based model of helping. I assert that by developing a
critical consciousness about the limitations of using a medical model, practitioners are able to
recognize that the social arena is an important factor shaping people's experience and lives
(Mullaly, 1997, 2002). Because the northern social arena strongly influences the way women
experience abuse and seek help, I will argue that it is critical for health care providers to
formally screen for abuse and that this process can be more meaningful when a empowerment
framework is used to guide practice. Women have reported that after receiving support,
validation and information from a caring health care practitioner they were able to take action
and gain more control over their lives (Hadley, 1992; Gerbert, Abercrombie, et al. , 1999). With
this in mind, the final section of this paper will demonstrate how using an empowerment model
of intervention to inform practice can enhance the universal screening process. I argue that
health care workers who are committed to an empowerment vision measure success in terms of
the process of screening, not by the number of women who disclose abuse (Gerbert, Caspers,
Bronstone, Moe, & Abercrombie, 1999; Gerbert, Abercrombie, et al., 1999). By viewing
women as experts on their own lives, the role of the practitioner is not to cure the problem, but
to facilitate empowerment. Biestek ( 1957) asserts that the job of the practitioner is to open the
doors and windows to let the air, light and sunshine in, as nobody can breathe or see for another
person. It is hoped that this case study encourages health care practitioners (and other allies in

7

the fight against woman abuse) working in northern communities to consider implementing a
formal universal screening policy based on principles of empowerment. In order to demonstrate
how universal screening can be an effective instrument for facilitating women ' s empowerment
in a northern, rural or remote community, the following topics will be presented:
•

The challenges facing women who are in abusive relationships in rural, remote or northern
locations

•

The personal, social, and economic consequences of violence against women

•

A literature review pertaining to universal screening of woman abuse and barriers which
prevent physicians and patients from discussing the issues

•

From a feminist perspective, an analysis regarding the limits of the bio-medical model of
health care as it applies to interactions with abused women

•

A description of the principles and values of an empowerment model of helping

•

The implications of applying the empowerment model to a policy of universal screening
with a focus on the northern context

•

Implications of screening for woman abuse for social work and health care

•

An evaluation of the policy and a discussion regarding future recommendations and research
aimed to better serve the needs of abused women seeking support from the health care
community in the north.
This case study begins with a description of some of the key concepts being used in this

paper. The upcoming section also offers an overview of the method of analysis being used and
the theoretical standpoint that guides my analysis.

8

Key Concepts
Master of Social Work Case Study: A Policy Issue

In accordance with the Master of Social Work project guidelines, I have chosen to
conduct a case study about the implications of using a screening policy for abuse in a northern,
rural or remote health care setting. Therefore, the focal point of my case is an administrative or
agency policy as opposed to a clinical case, which is concerned with the analysis of an
individual, group or community (Handbook for the Master of Social Work (MSW), 2000, p. 14).
"Policy" can be defined in many ways; however, the policy being used in this case study falls
more closely in line with the description provided by Westhues (1999). Offering a broad
conception of social policy, Westhues writes that social policy is "a course of action or inaction
chosen by public authorities to address a given problem or interrelated set of problems" (p. 239).
By "public authorities" Westhues ( 1999) includes decisions emerging from all levels of
government (federal, provincial, municipal) as well as social service organizations and
collective agreements which address social problems which "deal with human health, safety or
well-being" (p. 239). Clearly, a hospital-based protocol aimed at improving the health, safety
and well-being of victims of abuse fits this description.
Universal Screening

The primary premise of universal screening is that it differs from the more commonly
used targeted (i.e., discretionary) screening of high-risk patients. Instead of asking only those
patients who are suspected of being abused, universal screening entails "routine screening for
domestic victimization for all female patients over the age of 14, whether or not symptoms or
signs are present and whether or not the provider suspects abuse has occurred" (Johnson, 2000,
p. 9). A common way to approach the subject is for a nurse or physician to say something along

9

the lines of: "from my experience here in the emergency department, I know that abuse and
violence at home is a problem for many women. Is it a problem for you in any way?" (Hatchet
al., 1995, p. 11). While many hospitals and clinics may have guidelines and policies to help
inform their practice with abused women, few have officially or formally adopted a screening
protocol (Hatch, Grunfeld, Mackay, & Ritch, 1996). This case study explores the implications
·of using a formal policy of universal screening. Chapter six presents a more comprehensive
overview of the screening process.

Health Care Practitioner
The term "health care" is commonly referred to in this paper. Health care is defined as
those "activities designed to treat, prevent, and detect physical and mental disorders and to
enhance people's psychosocial well-being" (Barker, 1999, p. 211). The health care system
consists of physicians, nurses, hospital attendants, medical social workers and so on. For the
purposes of discussing the implications of screening in a northern or rural community, the term
"health care" mainly applies to emergency departments and/or family practice settings.
Therefore, the health care provider refers to the person in these settings who will be directly
involved in doing the screening, which is usually the emergency room physician, general
practitioner or nurse (often it is the nurse who is the first contact person for patients in an
emergency department). Besides emergency room settings, screening protocols have been
studied and utilized in a variety of other health care settings, including obstetrics, gynecology,
surgery, internal medicine and pediatrics (Johnson & Elliott, 1997).

10

The North
This paper is concerned with universal screening for woman abuse in a health care
setting from a northern perspective. Defining "north" is not an easy task, but necessary for
understanding how geography influences a woman's experiences with violence. The people who
make up Canada' s north are a diverse group of people. Therefore, this paper refers to women
living in a variety of settings such as farming, forestry, mining, fishing, tourism-based and
Aboriginal communities. The north is comprised of rural and remote elements as well as urban.
For example, cities like Sudbury, Prince George, Edmonton and Thunder Bay are northern cities
composed of both urban and rural elements (Delaney, 1995). McKay ( 1987) defines north by
separating it into two main areas: the near north and the far north. The near north, in which the
majority of the people are non-native, has an average winter temperature of -15°C. It includes
areas of land found on the southernmost border of the boreal forest and contains a number of
larger urban centres accessible by road, train and air (McKay, 1987). Near-north communities
have access to educational, health and social services, unlike most communities located in the
far north or remote regions (McKay, 1987).
Far or Remote North
The far north (or remote northern regions) consists mainly of remote communities of
mostly Aboriginal peoples that are often accessible only by air (Mackay, 1987). Compared to
many rural northern regions, remote northern locations experience much colder temperatures
and are often separated by vast distances between communities. Isolation is a significant
problem which is caused by extreme cold temperatures and transportation challenges due to
poor and unpredictable weather (Ingebrigston, 1985). Remote communities have greater
challenges sustaining adequate social, health and recreational services and frequently experience

11

outside government interference in local affairs (Ingebretson, 1985). Arges & Delaney ( 1996)
and Zapf ( 1991) argue that northern rural and remote communities share a history of
exploitation and colonization, and that the north is susceptible to economic and political
domination by the south.
Rural

The challenge in clearly defining "rural" is that there are so many different approaches
available (Zapf, 1991). Rural can be defined across geographic, population and economic lines.
However, some argue that strict geographic or population definitions can leave out important
sociological, political and even personal considerations that distinguish rural from urban (Lee,
1991). That is, for some "rural is as much a frame of mind as it is a place" (Coates & Morrison,
1996, p. 3). It is estimated that about one third of Canada's population is rural (Zapf, 1991).
From a policy and legislative perspective, Statistics Canada (2001b) defines rural and small
towns as communities with a population of 10,000 or less-those that are outside commuting
zones of large metropolitan areas and cities. Others (Zapf, 1991) state that rural populations can
range anywhere from 2500 to 50,000 people. From an economic perspective, rural communities
lack economic diversity as economies are typically based on single industries, such as
agriculture, fishing, forestry or tourism (Zapf, 1991 ). Characterized by an unsteady economy,
rural areas often have higher rates of unemployment and low levels of employment due to the
seasonal nature of the work (Ingebretson, 1985). Other common elements of rural life are low
population density, vast distances from urban centres, strong social connections, an ethic of selfsufficiency and limited health, social and recreational services (Lee, 1991 ). In addition, rural
residents generally adhere to more conservative and traditional values, have a strong church
presence, and rely more heavily on informal self-help and natural helping networks

12

(Ingebretson, 1985). Although "north" and "rural" are not synonymous terms, many of the
qualities ascribed to rural areas can also be applied to Canada's north (Ingebretson, 1985).
Woman Abuse
While there are many different definitions of "woman abuse" available, the one used in
1

this paper takes a feminist standpoint as opposed to a family violence perspective. I have
chosen the definition provided by DeKeserdy & MacLeod ( 1997) because it recognizes the
complexities that surround woman abuse. They write:
Woman abuse is the misuse of power by a husband, intimate partner (whether male or
female), ex-husband, or ex-partner against a woman, resulting in loss of dignity, control,
and safety as well as a feeling of powerlessness and entrapment experienced by the
woman who is the direct victim of ongoing or repeated physical, psychological,
economic, sexual, verbal, and/or spiritual abuse. Woman abuse also includes persistent
threats or forcing women to witness violence against their children, other relatives,
friends, pets, and/or cherished possessions by their husbands, partners, ex-husbands, or
ex-partners. (DeKeseredy & MacLeod, 1997, p. 5)
It is important to point out that few women endure physical abuse without also being
subjected to various forms of psychological abuse such as shaming, intense criticism, verbal
harassment, blaming, ridiculing and stalking (Walker, 1980; Loue, 2001). For many women,
"the slow emotional torture which produces invisible scars is as abusive as the quick, sharp
physical abuse" (Walker, 1980, p. 72). However, acts of physical abuse and psychological
cruelty are often accompanied by acts of kindness and promises that the abuse will not happen.
Key to understanding the complexities surrounding these dynamics is Lenore Walker's ( 1980)
"cycle of violence" theory. According to Walker (1980), the cycle of violence is characterized

13

by three phases: the tension-building phase; the explosion or acute battering incident; and the
peaceful, loving and often remorseful phase. Phase one, or the tension-building phase, is the
time verbal attacks and minor acts of violence take place. Following this is phase two, in which
there is typically an acute battering incident, tension reaches its peak and a violent incident
occurs. Immediately following this is the third phase, in which the abuser is typically
affectionate and loving. This final phase is where many victims find themselves believing that
the abuser is going to change his behavior and consequently, they decide to stay and give him
another chance (Walker, 1980). It is not difficult to see how living in this environment can,
often very slowly, erode a woman's self-esteem and sense of efficacy. About the complexities
involved in leaving a violent relationship, one interviewee states:
I was vulnerable, naive, blinded. I believed in a man I loved, and I did not believe he
would keep hurting me. I stayed with him, and I chose not to see the man I married, the
father of my three children, as a batterer who would always be a batterer. I saw each
incident as an isolated nightmare, all explained away, all forgiven. I didn't connect them
to see the pattern (Loue, 2001, p. 144).

14

CHAPTER TWO
Method of Analysis: Critical Thinking
"Critical thinking is at the heart of anybody transforming their lives" (bell hooks, 1997).
I have stated that this paper is a critical analysis of the implications regarding a screening
policy for use in northern or rural health care environments. In order to assist me in this process,
· I have used the critical thinking framework offered by Gibbs and Gambrill ( 1999). According to
Gibbs and Gambrill, critical thinking involves the "critical appraisal of beliefs, arguments and
claims in order to arrive at well reasoned judgments" (p. xiii). This is a necessary component of
social work (and other helping professions), as critical thinking may enable practitioners to
identify, change or improve policies in order to put the best interests of clients first (Gibbs &
Gambrill, 1999). It is important to note that critical reflection is not theory-free, because it is
based on certain fundamental beliefs and assumptions about society (Mullaly, 2002). In

Feminism is For Everybody: Passionate Politics, bell hooks (2000) points out that every
person's actions and thoughts are rooted in theory. Whether people are conscious of it or not,
hooks argues that there is an underlying system at work influencing the decisions and behaviors
people make (hooks, 2000). With this in mind, it is important to point out that the critical
analysis and ideas offered in this paper are informed by a number of different "voices of
authority." These voices include academic texts, journal articles, qualitative and quantitative
research studies and conversations with health care practitioners. However, the ideas that are
brought forward in this paper are also strongly shaped by my own educational, personal and
professional experiences. My education in sociology, psychology and social work, and my
training as a counsellor, all come together to shape the theoretical lens of this paper. Most
significantly, however, this paper is influenced by my previous employment as a feminist-

15

oriented counsellor, working with victims of abuse of different ages and working in various
capacities (as a transition house counsellor and coordinator, Crown counsel victim support
worker, Elizabeth Fry counsellor, and a primary school counsellor). Cultural studies researchers
refer to this way of weaving together information from many sources as "bricolage" or
"collage" research (Transken, 2002). Similarly, feminist scholars advocate for multi-method
research because "it creates opportunities to put texts or people into contexts, providing a richer
and far more accurate interpretation" (Reinharz, 1992, p. 213). The next section will reveal that
while I see the value in considering multiple perspectives (for example, psychological and
sociological) for understanding the complexities surrounding violence against women, I believe
that an explanation of woman abuse is enhanced when a feminist lens is used.
My Standpoint: A Multi-Focussed Feminist Lens
Women will not be free from violence until there is equality, and equality cannot be
achieved until the violence and the threat of violence is eliminated from women's lives.
(Canadian Panel on Violence Against Women, 1993, p. 4)
Many types of feminist scholarship have been developed, including socialist feminism,
Marxist feminism, liberal feminism and radical feminism, to name a few (Jaggar, 1983).
However, all forms of feminism generally agree that feminism is "a movement to end sexism,
sexist exploitation and oppression" (hooks, 2000, p. 1). What distinguishes the different forms
of feminism from one another is how they view the origins of women's oppression and how
they think the problem should. be addressed. The form of feminism I lean closest to is most
strongly informed by sociological theories (Gelles, 1983) and socialist feminism (Jaggar, 1983).
A sociological point of view takes into consideration that family violence is largely
shaped by the major social structures such as age, sex, socio-economic status, race, religion and

16

ability. A sociological standpoint also recognizes that social stress is a factor in cases of partner
abuse. While there is an understanding that violence cuts across all social and economic groups,
the risk of child abuse, wife abuse, elder abuse and so on is greater among those who are poor,
unemployed and who possess jobs of low prestige (Gelles, 1993). In addition, sociological
theories contend that wider social norms and media images condoning violence contribute to
violence being seen as a normal means for resolving conflict. "The frequent portrayal of coerced
sexuality in mainstream movies, music videos, television and pornographic materials provides a
backdrop for rationalizing gender violence in everyday interaction" (O'Toole & Schiffman,
1997, p. 71 ). Many feminist sociologists take the position that, while the media is a strong
influence in terms of passing on messages that condone violence, it is the structure of the
modern patriarchal family as a social institution which most strongly influences family violence
(Gelles, 1993; Smith, 1990; Walby, 1990).
From a socialist-feminist standpoint, it is necessary to examine the interrelationship that
exists between capitalism and patriarchy in order to understand how society and its institutions
promote and perpetuate a violent society (Jaggar, 1983). Some have argued that based on a
structure of hierarchy and exploitation of workers, the liberal democratic capitalist Canadian
society is in essence abusive in nature (Duffy & Momirov, 1997). Duffy & Momirov (1997)
assert that based on competition, self-interest, efficiency and rationality, capitalism results in a
situation in which few people enjoy economic prosperity while many are economically deprived
and become marginalized members of society. From a socialist-feminist perspective, it is this
relationship between patriarchy and capitalism that creates a culture of violence (Jaggar, 1983).
That is, a husband's use of violence against a partner is not a random, irrational act; instead it is
embedded in a patriarchal society which is "a system of social structures and practices in which

17

men dominate, oppress and exploit women" (Walby, 1990, p. 20). Being dominant means that
generally, men as a group have more privilege and access to resources, while women as a group
are devalued and viewed as secondary (Bograd, 1988). Bograd recognizes that while it is true
that there are significant social class and race differences among men, all men can potentially
use violence as a way to subordinate women (Bograd, 1988). Male violence (both the perception
of and actual act itself) is an expression of male power used by men to reproduce and maintain
this relative status and authority over women (Alder, 1997). Jaggar (1983) concedes that the use
of violence for control in marriage is not only perpetuated through norms about what constitutes
appropriate male roles and husbands' rights in marriage, but also through women ' s continued
economic dependence on their partners. Marriage based on a traditional sexual division of
labour, in which women are the primary child-care providers and housekeepers, and men are
responsible for the economic arena, contribute to women's dependency on husbands (Jaggar,
1983). Women's fear of violence, combined with economic dependence, is further complicated
by other structural barriers such as limited child care, housing options and support services
which create a situation in which women are often forced to remain in abusive homes (Jaggar,
1983). In addition to the family, patriarchy characterizes all other social institutions such as the
church, government and the agencies abused women have the most contact with: the law
enforcement agencies, the criminal justice system and the medical establishment (Duffy &
Momirov, 1997). This translates into a situation in which violence against women and children
is in effect sanctioned and reinforced both by individual partners and by the social institutions
women depend on (Duffy & Momirov, 1997).
I agree with the feminist position that violence cannot be understood without an analysis
of gender and power, and that attributing violence to interpersonal conflict or psychological

18

factors is simply not sufficient (Yllo, 1993). In other words, social-psychological theories often
point to social learning theory to explain why men are abusive and women are victims.
Similarly, psychological explanations for woman abuse tend to focus on the personal pathology
of the abuser: looking at childhood experiences, parental relationships and later use of violence
(Yllo, 1993). The problem with leaning too heavily on psychological explanations is that there
is too much emphasis placed on the psyches of the abusers and less on the role of history, social
institutions and dominant ideologies in explaining violent behavior (Duffy & Momirov, 1997).
Johnson (1996) cautions against assuming that witnessing violence as a child is a predictor of
future abuse. Referring to Canada's national Violence Against Women Survey, she states:
"While it is true that the rate of wife beating is much higher for men who have witnessed
violence by their own fathers , it is also true that the majority of abusive men were not exposed
to violence in childhood. And, over half the men who did have this exposure have not been
violent toward their own wives" (p. 177). With this in mind, I believe that psychological and
social learning theories both make important contributions to our understanding of violence
against women. However, having worked with survivors of abuse reinforces for me the value of
using feminist principles to inform practice. The primary benefit of using feminist principles to
guide practice with abuse survivors is that the focus of helping is not on changing individual
behaviors or getting people "to adapt to their oppressive environments" (Land, 1995, p. 14).
Instead, the focus is on helping women see how personal problems are both created by and
intensified by societal power imbalances (Burs tow, 1992).
The reason I advocate using an empowerment approach for screening for woman abuse
is that it is multi-faceted and reflects the principles and goals of feminism, anti-oppressive or
structural social work, and cultural studies. It is also the preferred model of practice for many

19

northern social workers (Delaney, 1995; Zapf, 1991). Empowerment practice is carried out by
linking political (structural) reasons to private troubles and communicating this back to those
who suffer from its damaging effects (Mullaly, 1997, 2002). Cultural studies is an important
element of empowerment practice because it emphasizes the notion of "multiplicity of
oppression," asserting that "multiple identities are a major influence on the production,
persistence and complexity of oppression" (Mullaly, 2002, p. 147). Cultural studies illustrates
how "the ruling hegemony is carried out at the level of everyday cultural practices-practices
that support a white, male, bourgeois, Eurocentric domination" (Mullaly, 2002, p. 84). Later in
the paper, I explore how empowerment values and practice are particularly concerned with
attending to the needs of vulnerable populations (Lee, 2001). The next section shows that one
vulnerable group that both health care workers and social workers are likely to encounter in the
north is women who are being abused by their partners. By exploring the multidimensional
nature of isolation, I will show how the northern landscape can create an untenable situation for
women trying to escape violence, particularly for women who are not members of mainstream
society.

20

CHAPTER THREE
Violence Against Women in Northern, Rural and Remote Communities
Six "gorgeous" children killed in house fire in remote island community. (Canadian
Press, March 11, 2002)
Headlines such as this one often evoke strong feelings of dismay and disbelief. The
tranquil picture of northern or rural life makes it difficult for people to believe that "domestic
violence" could occur in their community. However, as mentioned, all women, regardless of
ethnicity, economic background and geography, are vulnerable to violence (World Bank, 1997).

It must be pointed out, though, that the impact of violence is magnified for socially marginalized
women such as poor women, women with disabilities, older women, immigrant or refugee
women, First Nations women and rural women (Morrow, 2000; Canadian Panel on Violence
Against Women, 1993). Research indicates that although rural areas have lower crime rates in
general, rates of rural domestic violence can be as high or higher than in urban settings (BogalAllbritten, 1997; Elliott & Johnson, 1997; Petersen & Weissert, 1982). In some northern
Aboriginal communities, the rate of woman abuse is as high as 75 to 90% (Green, 1996). 2
The aspects of rural life that make it so appealing to many who choose to live there,
such as the solitude, simplicity and close-knit nature of the community, also create immense
challenges, particularly for abused women (Fishwick, 1998). Studies on rural partner violence
consistently cite isolation as a key factor of rural women's experiences with violence (Jiwani,
2001; Goekermann et al., 1994; Fishwick, 1998; Websdale, 1998; Beauregard, 1996; Edelson &
Frank, 1992; Greenard-Smith, 2002). Isolation is not unique to rural women. It is not
uncommon for abused women to be cut off from everyone they know except the abusive person,
regardless of where they live (NiCarthy, 1986). In addition to this kind of physical isolation, the

21

secrecy surrounding woman abuse often leaves many women feeling tremendously alienated
and alone (NiCarthy, 1986). However, as the next section will show, there are additional distinct
geographic, social, cultural and economic factors that influence the way northern women
experience violence and seek help. 3

The Key to Control: Isolation
Ensuring silence is key to an abuser's ability to maintain control and intimidation over
his partner. A common characteristic of violent men is that they are highly distrustful ,
possessive and jealous. Abusers will often use extraordinary measures and complex practices to
control their partner' s whereabouts, carefully monitoring whom she sees and where she goes
(Walker, 1980; NiCarthy, 1986). Despite constant surveillance, abusers are often extremely
suspicious of their partner's relationships, especially with other men (Walker, 1990). In the
written descriptions of ex-partner homicides completed by investigating police officers, fear of
infidelity was the central theme for male offenders. The police also note that the most common
motive among men for killing an ex-partner was jealousy (41%) (Statistics Canada, 200la). An
abusive spouse will often keep his partner away from her friends and family and prevent her
from working outside the home. This isolation ensures that potential sources of help are never
contacted, and thus women begin to believe that their situation is one of a kind (NiCarthy,
1986). Without an outside "reality check," women start to believe that they must be to blame for
the violence, and they are prevented from learning that there are alternatives to living with
violence (NiCarthy, 1986). Those who do find the courage to speak out and flee their abusive
surroundings often discover that breaking the silence is only the first hurdle they must
overcome.

22

Barriers to Escaping the Violence
Women stay in abusive relationships for a variety of often complex and interconnected
reasons. Some of these include staying for the children; for love; for lack of financial
independence; for lack of job opportunities; for lack of life skills; for fear of deportation and,
most notably, for fear of partner retaliation (McTimoney, 1993).
The unfortunate reality for many women is that staying in an abusive marriage or
relationship is not the worst thing that can happen to them (Bowker, 1993). Studies show that
attempting to leave an abusive partner can and does lead to escalated violence and even murder
(Wilson & Daly, 1994). Leaving may be especially dangerous for rural women, as some studies
suggest that the highest rates of spousal homicide take place in the more rural parts of Canada,
such as the western provinces and territories (Gurr, Mailloux, Kinnon, & Doerge, 1996). Some
abused women would rather expose themselves to violence and try to protect their children than
risk losing custody of their children to a violent man (Bowker, 1993 ).

Violence and Poverty
A significant barrier for women trying to flee an abusive relationship is related to their
socio-economic status. Women in Canada are at higher risk of living in poverty than are men
(Status of Women Canada, 1995). Among the women who currently live in poverty, there is an
overrepresentation of older women, single mothers, immigrant women, women of colour and
disabled women, as well as Aboriginal and rural women (Gurr et al., 1996). Poverty is often a
two-way street when it comes to violence against women in relationships. On the one hand it
can contribute to violence, and on the other hand it can be the result of leaving a violent
relationship. Poverty is associated with higher unemployment, subsistence housing and greater
family stress and conflict (violence). Given that an abused woman's economic security is

23

largely dependent on her husband' s income, moving out of an abusive relationship often means
moving into poverty (Lochhead & Scott, 2000). With the current cutbacks to British Columbia' s
social assistance benefits and other programs (i.e., 18% reduction for single mothers, cutbacks
to child-care resources, etc.), the welfare option for abused women today is dismal at best. A
single mother with two children will need to clothe, house and feed her family on less than
$1000 per month (B .C. Ministry of Human Resources, 2002). Single mothers who work outside
of the home (usually for minimum wage) instead of collecting social assistance are seldom
better off (B.C. Coalition for Women's Centres, 2002). For many women, returning to work
often means losing prescription, dental and vision benefits and housing and child-care subsidies.
For many women, getting a job essentially means making the shift from the unemployed poor to
the working poor (Davies, McMullin, Avison, & Cassidy, 2001).
Institutional & Structural Barriers
While all women in society face similar socio-economic obstacles when it comes to
fleeing abuse, there are distinct structural elements that exist in many rural or northern
communities that make escaping violence in these settings particularly challenging (Websdale,
1995; Krishnan, Hilbert, & Van Leeuwen, 2001). Northern or rural women typically have less
formal education, fewer job opportunities, less job security and benefits, and fewer housing and
child-care options than their urban counterparts (Schissel, 1992). A comprehensive discussion
about the subject of family violence in Aboriginal communities goes beyond the scope of this
paper. However, it is important to point out that these socio-economic conditions are felt even
more profoundly by many Aboriginal families (LaRocque, 1994 ). Many believe that the
widespread abuse of Aboriginal women and children is integrally linked to a long history of
exploitation and cultural genocide (Green, 1996; Royal Commission on Aboriginal Peoples,

24

1996). Family violence in Aboriginal communities is attributed to the daily stress of living in
poverty, financial hardship, as well as high rates of alcohol and suicide, resulting in chronic
despair for many Aboriginal families today (Royal Commission on Aboriginal Peoples, 1996;
Canadian Panel on Violence Against Women, 1993).
Combined with numerous socio-economic barriers, rural women's isolation and
dependency is further magnified due to inadequate sources of formal support such as transition
houses, counsellors, women's support groups, social and health care services and culturally
relevant services (Greenard-Smith, 2002; Krishnan et al., 2001 ; Jiwani, 2001; Websdale, 1998).
For women who reside in more remote areas, most of whom are First Nations women, the only
way to get to a transition house is by boat or plane (Greenard-Smith, 2002; The Canadian Panel
on Violence Against Women, 1993). Further complicating the problem is the challenge northern
women face in terms of finding service providers who are knowledgeable about the dynamics of
abuse and sensitive to their concerns (Greenard-Smith, 2001). In addition, for women accessing
these limited supports, maintaining privacy, anonymity and confidentiality is exceedingly
difficult in smaller communities (Fishwick, 1998; Websdale, 1998; Goeckermann, Hamberger,
& Barber, 1994). Women are likely to know or be acquainted with those who are in a position to

help them, such as social workers, clergy, police officers, court workers and hospital staff. For
many women in rural areas, seeking help means risking being blamed for the abuse and
ostracized (Jiwani, 1998; Canadian Panel on Violence Against Women, 1993).

Social/Cultural Isolation
Violence is a secret; [it is] never discussed because it threatens the webs of relationships
which hold rural communities together. (Canadian Panel on Violence Against Women,
1993, p. 71)

25

As mentioned, despite evidence that shows that rural family violence is a major problem,
it is still commonly believed that rural areas are immune to these issues (Websdale, 1998; Gurr
et al., 1996). Some of the characteristics of rural life that were discussed earlier in this paper
play an integral role in contributing to this misconception about woman abuse. Studies have
shown that many rural people believe strongly in the "sanctity of marriage" and religious values,
and are less tolerant of minority rights (Fish wick, 1998). According to Websdale ( 1995), "rural
patriarchy" characterizes these communities, meaning that traditional sex-role division is more
common. In other words, it is the norm for men to assume the breadwinner role and women to
assume primary responsibility for child rearing and housework. Added to this is an attitude that
domestic violence is a family issue and not a community problem, as well as a strong adherence
to values of self-reliance and independence (Fishwick, 1998; Websdale, 1995). Violence may
also go unreported because women are hesitant to call the police due to negative attitudes and
what Websdale (1995) refers to as a problem of "passive policing" in these regions.
Furthermore, in cases where criminal or unsavory activities are taking place (for example,
illegal firearms, marijuana growing, welfare fraud, etc.) women may feel that calling the police
is not an option. What all this means is that rural women in these complex circumstances are
reluctant to seek outside help or to report the abuse, and the conspiracy of silence and violence
continues (Websdale, 1995).
For women who are not members of the dominant culture (that is, immigrant women,
lesbian women, First Nations women), living in a small community may present different
challenges. For example, some immigrant women living in the north may not be able to ask for
help because of cultural and social isolation, language barriers, discrimination and fear of
deportation. Like many rural women, immigrant women often have strong values around

26

dedication to family unity (Jiwani, 1998). A woman with strong religious or cultural values may
feel that her community will shun her if she leaves her abusive marriage (Bowker, 1993; Status
of Women Canada, 1993). New immigrants often report feeling powerless when seeking help in
a completely new setting, with little knowledge about law enforcement, legal rights or the
availability of shelter services or social services (Bauer, Rodriguez, Szkupinski Quiroga, &
Flores-Ortez, 2000.) For women who speak very little English, reaching out for help is not only
difficult but dangerous because they are often completely dependent on their abusive partner to
drive them to appointments and interpret for them (Jiwani, 2001). For rural women in same-sex
relationships, asking for help can be highly anxiety provoking. A woman residing in a northern
town in Ontario recalls how the fear of being exposed affected her daily life: "Living closeted in
a straight community .. .! was afraid to be open with anyone .. .! used alcohol to avoid dealing with
my fear" (Beauregard, 1996, p. 236). In Aboriginal communities, some women fear that
speaking out about the violence could lead to further victimization by local leaders, most of
whom are male (Royal Commission on Aboriginal Peoples, 1996). Aboriginal women's
reluctance to speak out also comes from a fear of exposing their communities to contempt or
their families to outside intervention (Royal Commission on Aboriginal Peoples, 1996).
Physical Isolation

I have presented some of the broader structural, institutional and social/cultural barriers
that contribute to northern women's increased dependency and isolation. Although these factors
are being presented individually, it is important to point out that these various forms of isolation
intersect with one another and operate in a way that is mutually reinforcing. For example, the
physical milieu of the north, which offers privacy and seclusion from others, makes it easier for
abusive partners to engage in violent behaviors that would be harder either to carry out or to get

27

away with in urban areas (Websdale, 1995). In addition, because of the cyclical nature of
partner abuse and the extended length of time it takes a rural woman to leave her partner, it is
more likely she will be exposed to more serious forms of abuse for a longer period of time
(Websdale, 1998). For example, women ' s dependency is intensified because seasonal jobs are
more common in these regions, leading to an abusive partner spending extended periods of time
at home. Hence, economic conditions set the stage for increased and enduring opportunities for
violence, and at the same time women have access to limited sources of support (Goeckermann
et al., 1994).
Websdale (1998) makes an important point, stating that geographic isolation is often the
result of a calculated decision on the part of the batterer to reside in the country. Geography
means that seeking help from neighbours is hampered by distance (some farms , for example, are
kilometres apart, not metres) (Fishwick, 1998). Geography is also a factor in the kinds of tactics
used by abusers, such as removing the phone receiver to cut off outside contact; locking the
thermostat in the winter; keeping track of the odometer reading to restrict movement (which is
particularly effective when there is no alternative mode of transportation); driving recklessly to
intimidate the woman ; and discharging firearms. Research shows that the presence of dangerous
tools and weapons is more common in rural households than in urban (Fishwick, 1998). Other
geographical factors, such as poor roads, lack of public transportation and extreme weather,
make accessing supports and fleeing an abusive relationship at times virtually impossible
(Goeckermann et al., 1994; Greenard-Smith, 2002). A northern BC transition house worker
attests to this fact, stating: "At 40 below, you can't even get in the car when you are running."
(Greenard-Smith, 2002, p. 62). Moreover, distance, poor roads and dangerous weather
conditions often lead to inadequate responses by emergency services such as police and

28

ambulance, clearly putting women (and drivers) at risk of serious injury and even death
(Websdale, 1995; Greenard-Smith, 2002). In addition, rural women may not get the help they
need in a crisis because telephone subscription rates tend to be lower and cell phone service is
confined to certain geographic areas (Websdale, 1998; Greenard-Smith, 2002).
The aim of this section has been to demonstrate that violence against women in
relationships is a serious social problem facing a substantial number of women of all ages,
classes, cultures, religions and geographic locations. Isolation is a central feature of most
abusive relationships. The primary difference between rural abuse and urban abuse lies in the
way the many faces of isolation intersect with one another. More specifically, geography merges
with social, cultural and economic conditions in a way that intensifies a northern woman ' s
dependency, increases her risk of enduring victimization and diminishes her ability to escape the
abuse. The human and economic costs of women's victimization are far-reaching. As the next
section demonstrates, violence against women results in serious emotional and physical
consequences at the individual level, but also negatively impacts society at large.

29

CHAPTER FOUR
Women, Violence & Health

Well she finally got the nerve to file for divorce; She let the law take it from there
But Earl walked right through that restraining order; And put her in intensive care.
(Lyrics to "Goodbye Earl," Dixie Chicks, 1999)
The Many Costs of Woman Abuse
The costs of gender violence are difficult to assess. However, whether the violence takes
place in an urban or rural setting, the effects are far-reaching. The costs of violence against
women are not restricted to the victim and her children, but also have indirect effects on
communities and society at large. Violence not only generates a general climate of fear and
insecurity, but it also stands in the way of women's full economic and social development. By
draining women's energy and eroding their sense of self-worth, abused women are denied the
ability to participate as full members of society (Garcia-Moreno, 1999; Heise, 1994). Being
controlled and victimized by a partner reduces a woman 's confidence and her ability to work
outside the home or to attain an education. The World Health Organization reports that women
of reproductive age in industrial countries lose one out of five healthy days of life because of
domestic violence and rape (World Bank, 1993). Canada's national Violence Against Women
Survey revealed that 30% of battered wives had to cease regular activities due to the abuse, and
50% of women had to take sick leave from work because of the harm sustained (Rodgers,
1994). Moreover, being isolated means that women are denied access to vital information and
support, and it makes it difficult for them to care properly for themselves or their children.
Canada's national Violence Against Women Survey indicated that approximately 4 in 10
women (39%) reported that their children witnessed the violence (Rodgers, 1994). Witnessing

30

violence not only instills fear and anxiety in children, but it can be detrimental to their social,
emotional and behavioral development (Jaffe, Wolfe, & Wilson, 1990). A serious outcome for
children exposed to violence at home is an increased risk of being physically or sexually abused
themselves and repeating the cycle of violence (Jaffe et al., 1990).
The economic costs of violence against women not only impact the lives of Canadian
women, but violence puts financial pressure on governments, businesses and institutions. In
terms of medical or health costs incurred, it is known that victims of violence use a
disproportionate amount of health services including emergency room visits, primary care and
community mental health centers (Plichta, 1992; Koss, 1994; Day, 1992). The Canadian
Violence Against Women Survey demonstrated that four in ten women injured by a partner, or
over half a million women, saw a doctor or nurse for medical attention in 1993 (Rodgers, 1994 ).
Day ( 1995) estimated medical costs associated with treating abused women in Canada in 1992
to be $1.5 billion. Clearly, these numbers do not adequate! y measure the true cost of partner
abuse. Not included in these reports are the non-quantifiable costs of violence such as the
emotional and physical suffering, breakdown of quality of life and in many cases loss of life
(World Bank, 1997).
Health Consequences of Woman Abuse

Victims of violence often sustain a range of serious physical injuries and psychological
problems resulting in broken bones, disfigurement, disability and suicide (Abbott & Willamson,
1999; World Bank, 1997). Physical, sexual and emotional abuse can lead to hypertension,
digestive problems, migraines, visual impairments, asthma, chronic pain and other stress-related
health concerns such as substance abuse problems, depression, anxiety and insomnia (Heise,
1994; Trypuc, 1994; Plitchta, 1996). Furthermore, the safety of a woman's unborn child is at

31

risk as it is common for violence to begin and/or escalate during pregnancy (Campbell, 1991).
Physical and sexual abuse during pregnancy can lead to low birth weight, miscarriage, maternal
mortality and other reproductive problems such as unsafe abortions, chronic pelvic pain and
sexually transmitted diseases (United Nations Population Fund, 2000).

Health Care Response to Abused Women
Stark, Flitcraft and Frazier ( 1979) were among the first researchers to document the
incidence of domestic violence among American women presenting in emergency rooms with
medical or psychiatric complaints. They found that 19% of women trauma patients who came to
a hospital emergency room were either confirmed as or very likely to have been battered (Stark
et al., 1979). Today, estimates of the percentage of women presenting to emergency room
departments or other health care settings as a direct or indirect result of partner violence vary.
However, a recent review of previous studies led researchers Rodriguez, Bauer, McLoughlin, &
Grumbach ( 1999) to estimate that between 31% and 54% of women who visit an emergency
department report a history of domestic violence.
Despite the fact that substantial numbers of abused women regularly seek health care
services, the medical community generally has a poor record in terms of detecting abuse and
responding appropriately to victims (Baer, 1997). For example, in her review of the literature on
woman abuse and health care utilization, Plichta ( 1992) reports that detection of abuse by
emergency room physicians is low, even when the injury is directly due to abuse. It is estimated
that only 5% of cases are presently being identified in emergency room departments (Lydon,
1996) and 3% detected in primary care settings (Thompson et al., 1998). Furthermore, in cases
where physicians have detected woman abuse, some women have found providers to be
unhelpful, unsupportive, disinterested, uncomfortable and blaming (Gerbert, Abercrombie, et

32

al., 1999; Plitcha, 1992; Varcoe, 1997; Warshaw, 1993; Kurz & Stark, 1988; Yam, 2000;
McCauley et al., 1998; Jiwani, 1998; Mehrotra, 1999; Transken, 1995). In a U.S . study, 1000
abused women ranked physicians after clergy, police and social and legal services for their
effectiveness in dealing with violence (Brentro & Bowker, 1989). Although the majority of
studies on this subject have been carried out in the US, similar studies conducted in Canada,
Australia and the United Kingdom suggest that abused women' s dissatisfaction with the health
care system is not restricted to the United States (Ferris & Tudiver, 1992; Lydon, 1996; Bates &
Brown, 1998; Abbott & Williamson, 1999).

A Call for Action
In response to the problem of poor detection rates and ineffective responses to abused

women, routine screening tools have been developed for use in various health care
environments. Many studies demonstrate that the use of a screening protocol creates an
opportunity to increase (sometimes dramatically) the identification and referral rate of intimate
partner violence (McLeer & Anwar, 1989; Morrison et al., 2000; Larkin, Hyman, Mathias,
D'Amico, & MacLeod, 1999; Olson, Anctil , Fullerton, Brillman, Arbuckle, & Sklar, 1996).
Research also suggests that the quality of physician response is better in settings where
screening protocols for domestic violence are in place (Kurz, 1990; Jiwani, 2001). In their study
at the Medical College of Pennsylvania, McLeer & Anwar ( 1989) found that after taking a
thorough trauma history from every non-motor-vehicle-accident trauma patient using a 15
minute triage interview, the detection rate of domestic violence increased from 5.6% to 30%
(McLeer & Anwar, 1989). In addition, Larkin et al. ( 1999) found that in a Pittsburgh emergency
department, the detection rate of abuse in women patients went up from 1% to 18%, even when
the universal screening tool was not used consistently among staff. Similarly, a study conducted

33

by Olson et al. ( 1996) revealed that the proportion of domestic violence cases identified in a
large urban trauma centre almost doubled after putting a one-question stamp on the patients'
charts (e.g., "is this visit related to domestic violence?"). Unfortunately, despite support shown
by professional associations for screening for woman abuse, health care providers generally fail
to routinely screen for violence (Campbell, 2001; Warshaw, 1994; Kurz & Stark, 1988;
Morrison et al., 2000). According to Grunfeld et al., ( 1996) it is not sufficient to informally
encourage hospitals to adopt guidelines concerning domestic violence, as this has not been
adequate to ensure widespread adoption and implementation. The reasons why physicians are
reluctant to screen for abuse are complex. It is evident, however, that the problem of abuse
going undetected is connected not only to physicians' reluctance to ask about violence, but also
to women's reluctance to discuss the issues (Gerbert, Abercrombie, et al., 1999). The aim of the
next section is to shed some light on this dilemma by critically examining some of the most
common barriers identified by health care providers and patients respectively.

Barriers to Discussing the Issues
I don't know why it should be frustrating to us. I think it's because we feel powerless.
And physicians don't like to think we're powerless. (Roux & Rittmayer, 1999, p. 174)

Physician/Nurse Barriers
The reasons behind health care providers' reluctance to inquire about family violence
issues appear to be varied. Some of the most commonly cited reasons are lack of time,
education or training; lack of referral options; fear of offending the patient; identifying too
closely with the patient; feelings of inadequacy; inability to control the situation or fix the
problem; underestimating the scope of the problem; and frustration with women returning to
abusive partners (Yam, 2000; Parsons, Zaccaro, Wells, & Stoval, 1995; Burgh, 1989; Sugg &

34

Inui, 1992; McGrath, Bettachi, Duffy, Peipert, & Becker, 1997; Rodrigues et al. , 1999). It is
worth investigating some of these issues more closely.
Lack of time. Time is frequently cited as a barrier for effective intervention with victims

of violence. Emergency room physicians and nurses work under severe time restraints, and
therefore many feel too pressed for time to engage in a complex and potentially emotional
·encounter with their patients (Baer, 1997). However, brief screening tools have been developed
that take into consideration the busy milieu of the emergency room. These tools, although brief,
can still enable nurses and doctors to deal with this issue effectively and in a caring and
professional manner (Morrison et al. , 2000). Furthermore, given the long-term economic and
personal costs of violence against women, the time spent on repeat visits for related
consequences of violence over the long run is far greater than the time it would take to address
the issue as early as possible (Ingram, 1994; Warshaw, 1994 ).
Lack of referral options. Some doctors are concerned that they will be opening

"Pandora's box" by asking about abuse if they have few referral options to offer their patients
(Sugg & Inui, 1992). Some rural physicians (Dr. Leiski, personal communication, April25 ,
2002) have identified this as a substantial barrier to screening for abuse. While it is
understandable for doctors to be reluctant to ask about abuse when there are few programs and
resources in which to refer their patients, I would argue that screening for abuse is necessary for
precisely this reason. As stated, the number of women who seek health care services for

violence-related injuries is significant (Plitcha, 1992). The emergency department is open 24
hours a day, making it an ideal setting for abused women to receive treatment, safety and
support. The 1993 Canadian Violence Against Women Survey showed that four in ten women
who were in violent relationships saw a medical doctor, whereas only 8% contacted a shelter

35

and fewer, 6%, stayed in one (Rodgers, 1994). Derk and Reece (1989) argue that it is imperative
for health care providers in rural and other underserved areas to pay particular attention to their
abused patients. Rural or northern providers may be the only people with whom the woman has
contact, who can assist with developing a safety plan, and who can reassure the woman that the
violence is not her fault violence. (Derk & Reece, 1989).

Lack of training/education or skill. Many health care providers are reluctant to ask about
violence because they feel that they lack the training or skills required to effectively help their
patients (Sugg & Inui, 1992). Despite a growing awareness of the medical consequences of
violence against women, health care providers today receive little training in working with
domestic violence victims (Bates & Brown, 1998). A recent study indicates that despite the fact
that more schools now offer curriculum in family violence, students receive an average of only
two hours of training (Alpert, Tonkin, Seeherman, & Holtz, 1998). Later in this paper I will
argue that training about the dynamics of abuse in relationships is essential to effective
intervention and treatment of abused women. Without it, health care providers are likely to react
to victims of abuse or rape the same way lay people do, which is to question the patient's
credibility and culpability for the offence (Koss, 1994). Furthermore, without education about
the prevalence of woman abuse, physicians may underestimate the magnitude of the problem. In
one study, physicians estimated the incidence of wife abuse in their practice at less than 2%
(Baer, 1997). It is encouraging to note, however, that Canadian family physicians are reporting
that they would like to receive more education on the subject of woman abuse (Ferris &
Tudiver, 1992). This is a step in the right direction, because some research suggests that
physicians who receive training on woman abuse are more likely to detect violent incidents
(Parsons et al., 1995).

36

Fear of offending the patient. Another obstacle to screening for abuse is physicians' fear
of offending patients. Studies show, however, that these fears are generally unfounded (Hotch,
Grunfeld, Mackay, & Cowan, 1996; Gerbert, Abercrombie, et al., 1999). Researchers find that
women are pleased that their physician is open to discussing the problem and women who are
not abused are not offended to be asked (Ministry of Women's Equality, 1999; McLeer &
Anwar, 1989). An informal, anonymous survey given to emergency room patients revealed that
96% of respondents supported the Vancouver Hospital's screening program (Grunfeld,
Ritmiller, Mackay, Cowan, & Hotch, 1994). Some authors point out that screening for violence
is not unlike screening for other sensitive issues such as substance abuse, depression, sexually
transmitted diseases and breast cancer (King, 1998).
Inability to control the situation or "fix" the problem. A physician' s reluctance to
intervene may be grounded in beliefs about his or her role and what is considered a successful
outcome in the screening process (Cole, 2000; Gerbert, Caspers, et al., 1999). Some doctors
believe they are trained to take charge and fix problems, but dealing with woman abuse
challenges their perception of themselves as "healers" and demands a new set of skills (Baer,
1997). Some doctors simply feel powerless and frustrated, stating:" ... you don't want it to
happen to your patients. It's depressing. And it's difficult. It's hard to fix. You may not be able
to fix it" (Roux & Rittmayer, 1999, p. 175).
Frustration with women returning to abusive relationships. Some health care
practitioners believe that it is not worth bothering to intervene in cases of domestic violence
because the woman will not leave the relationship or access the services offered anyway (Roux
& Rittmayer, 1999). The position taken here is that the priority in the screening process should

not be the number of women who disclose abuse, nor should it be focussed on getting women to

37

leave their partners or access supports. Given the secrecy and shame surrounding the abuse, it is
not unusual for women to be evasive and even uncooperative when asked about the violence
(Kurz, 1990; Varcoe, 1997). It is important to note that while a woman may not be ready to talk
about the abuse or be open to suggestions about leaving her abuser, knowing that her physician
is willing to broach the subject might make a difference the next time she seeks help (Warshaw,
1994). In the upcoming chapter on empowerment practice, I will explain in greater depth why
success in screening, as Gerbert, Caspers, et al. ( 1999) point out, should be about the act of
compassionate asking about violence itself, not necessarily full disclosure.
Patient Barriers to Disclosing Abuse
I think that going to a hospital for domestic violence is like going to the sexually
transmitted disease clinic ... you feel like the doctors look at you like you're dirty or you
weren ' t protecting yourself. (McCauley et al., 1998, p. 552)
Women seeking health care services are hesitant to discuss the issues for many of the
same reasons that prevent them from disclosing abuse to other helping professionals. A few of
the most frequently reported barriers for women disclosing abuse are fear of partner retaliation;
lack of privacy; shame, embarrassment and denial; cultural barriers; and fear of being
misunderstood, discriminated against or blamed for the violence (Jiwani, 2001; McCauley et al.,

1998; Yam, 2000; Gerbert, Abercrombie, et al., 1999). After exploring each of these issues at
greater length, this section will discuss some additional obstacles facing abused women seeking
health care services in northern, rural or remote communities.
Fear of partner retaliation and lack of privacy. Understandably, women are often fearful
that their partner (or someone associated with their partner) could find out about their disclosure
of abuse and this could lead to retaliation. Clearly, women are prevented from disclosing abuse

38

if their partner accompanies them to the hospital, which is a common strategy used by abusers to
ensure their partner's silence (Lydon, 1996). The lack of privacy, confidentiality and anonymity
afforded women in hospital settings reduces the likelihood that women will feel comfortable
talking about the violence (Yam, 2000). This lack (or perceived lack) of privacy, confidentiality
and anonymity represents one of the most substantive barriers for rural women disclosing abuse
(Websdale, 1998; Fishwick, 1998; Canadian Panel on Violence Against Women, 1993). Dual
relationships can be a significant problem for both practitioners and patients in rural areas. It is
not unusual for health care providers to be related to or acquainted with patients' families. For
example, some rural women have told their physicians that their injuries were accidental
because they knew someone in the waiting room (Jiwani, 2001). Similarly, a rural American
woman states:
Now I'm not about to tell what's going on at home to anyone at that clinic. Two of his
cousins work there. If they find out that I mentioned this, they will just report it back to
him [her husband]. And that would make life even worse for me. (Fishwick, 1998, p.
287)

Cultural barriers. The imbalance of power that exists between a patient and physician
can make disclosing abuse particularly difficult. Feelings of apprehension around discussing the
violence may be further heightened for women from cultures with strong taboos against seeking
help (Jiwani, 1998; Bauer et al., 2000; Mehrotra, 1999). For example, talking about the violence
with a health care provider may be anxiety provoking for a woman whose first language is not
English and who has been told that if she talks about the violence she could be deported (Bauer
et al., 2000).

39

Shame, denial, and embarrassment. The dynamics of violence against women in
relationships are such that women often internalize blame and assume responsibility for their
partner's abusive behavior (NiCarthy, 1986; Walker, 1990). Given that many abused women
have feelings of intense embarrassment and shame, it is not surprising that they may want to
keep the violence a secret (Gerbert, Abercrombie, et al., 1999; McCauley et al., 1998). It is not
· uncommon for women to minimize, deny or lie about the origins of their injuries:
.. .it wasn't like he was beating me, so I didn't quite get it. So if someone would have
asked me, I mean, [I would say] "My husband doesn't beat me, no" ... I was in a lot of
denial. (Gerbert, Abercrombie, et al., 1999, p. 122)
Despite feeling embarrassed and reluctant to disclose abuse, women generally appreciate
being asked about the abuse. Many state that they are often relieved and even expect to be asked
by their physician (Gerbert, Abercrombie, et al., 1999). One study showed that rather than
directly disclosing abuse, some women felt more comfortable dropping hints or offering an
"invitational disclosure" in hope that this would lead to more questioning by the physician
(McCauley et al., 1998). Similarly, Gerbert, Abercrombie, et al. (1999) found that in terms of
addressing domestic violence, the physician and the patient engaged in a "dance of disclosure."
Instead of directly talking about the violence, both the physician and patient provided hints and

clues about the possibility of abuse (Gerbert, Abercrombie, et al., 1999). However, it is
important to point out that some research shows that women will only disclose abuse if asked
directly about it (Hayden, Barton, & Hayden, 1997).
Negative attitudes and cultural stereotypes. Studies show that many women are afraid to
volunteer information about abuse because they are afraid their concerns will be dismissed or

40

they will be blamed for the abuse (Yam 2000; McCauley et al. , 1998). In some cases, their fears
are well founded:
The doctor asked: What happened? I said, "My boyfriend hit me with a bottle." The
doctor asked, "What did you do?'' She stated, "What did I do? What could I do? He sent
me for x-rays, removed the glass and cleaned my eye." (Yam, 2000, p. 467)
In the medical records reviewed by Kurz & Stark ( 1988), patients who returned for
medical treatment due to violence were often identified and labelled as "repeat patients,"
"crocks," "hysterics" or "neurotic females." In other cases, women have been diagnosed with
"somatization disorder," "self-defeating personality disorder" or "borderline personality
disorder" (Warshaw, 1994). For women who developed other post-traumatic symptoms from the
abuse such as anxiety, depression or substance abuse, their credibility was further questioned
(Warshaw, 1994). Studies show that rather than exploring other options for the injuries women
have sustained, they are often prescribed medications to treat their "psychiatric diagnosis" or
"adjustment disorders" (Stark, Flitcraft, & Frazier, 1979; Warshaw, 1993).
For some minority women, entering the health care system can be anything but
empowering. Studies in both Canada and the US reveal that immigrant women and women of
colour are reluctant to discuss issues of abuse for fear of being discriminated against by health
care providers (Jiwani, 2001 ; Bauer et al. , 2000). These studies reveal that health care providers
have a tendency to dismiss immigrant women's health care issues. In a U.S. study conducted by
Bauer et al. (2000), many immigrant women found their encounters with health care providers
to be characterized by racial and ethnic prejudice, leaving them feeling disempowered,
mistreated and disconnected. Regarding her experience with the health care system, one woman
states:

41

Doctors are not capable of asking if you have a problem in the house. No, they don't ask
you. And I think they should at least try to be more human, because they use a lot of
discrimination because you're Latino and you notice the difference when an American
arrives, they behave very kindly, "No, go ahead, sit down," and you're so aware of the
difference, the brusque change of how they treat you and how they treat the others.
(Bauer et al. , 2000, p. 5)
Similarly, in a study conducted in northern British Columbia, some First Nations women
reported feeling disconnected or viewed as "other" or outside of the mainstream health care
system (Browne, Fiske & Thomas, 2000). In their research studies on abused women's
encounters with the health care system in British Columbia, both Jiwani (2001) and Varcoe
(200 1) contend that immigrant women and women of colour are "racialized" by the health care
system. In Jiwani ' s (2001) opinion, nurses and doctors have an emotional white-out when it
comes to offering help to immigrant women of colour. In her qualitative study, Jiwani (2001)
found that nurses assigned women "deserving" status if the women were willing to leave the
abusive relationship. When staff felt that they were contributing to something "valuable" by
rescuing the woman, her status was elevated to that of a preferred patient (Jiwani, 2001).
Similarly, Varcoe (1997) found that non-white women, poor women, women who were
substance abusers and those who did not leave their abusive partners (so-called "frequent
flyers"), were labelled undeserving by nursing staff, while those who did not fit into that
category were deemed deserving. Some believe that this labelling process is the effect of women
being seen as evasive or uncooperative in the health care encounter, and as a result the staff
view them as "deliberate deviants" (Warshaw, 1994; Kurz, 1990; Varcoe, 1997). In other words,
women who refuse to change their situation are seen as causing their own problems and

42

therefore they should not be making claims on already scant medical resources (Kurz & Stark,
1988; Varcoe, 1997).
Additional barriers for rural women seeking health care. In order to understand abused
women ' s experiences wit~ the health care system in northern, rural or remote communities, it is
important to be aware of some of the broader health care issues facing those who live there.
Generally speaking, residents living in northern or rural settings have a more difficult time
accessing adequate health care services than do urban residents. Health care workers in these
areas are under more stress due to a number of problems including staff shortages, difficulties
recruiting and retaining physicians, hospital closures, lack of specialty services and difficulty
accessing timely emergency care (Johnson, 2000; BC Centre of Excellence for Women ' s
Health, 2000). These problems affect everyone who lives there, but they are particularly
problematic for abused women seeking health care services. First of all, while it is true that both
urban and rural women may encounter insensitive health care providers, women in isolated
communities are at a further disadvantage because they have fewer medical alternatives (BC
Centre of Excellence for Women ' s Health, 2000). Often there is only one medical setting
available to serve the whole community in smaller northern towns. Women who have had
negative interactions are more likely to avoid health care services altogether, accessing them
only in life-threatening or critically ill circumstances (BC Centre of Excellence for Women's
Health, 2000). This was the case for some First Nations women in northern BC who described
their interactions with mainstream health as being so negative and invalidating that it
discouraged them from seeking help altogether (Browne, Thomas, & Fiske, 2000). Secondly,
women who have felt helped by health care practitioners report that it is the quality of the
patient-doctor relationship that facilitates disclosure of abuse (Gerbert, Abercrombie, et al.,

43

1999). However, establishing trusting, quality relationships may be much harder to accomplish
in a rural community where physician and nurse turnover is high. A final barrier for women
seeking health care in northern, rural or remote areas is that it may be more of a challenge to
rally support for programs and services that deal with violence against women issues because
these communities tend to be more conservative and traditional in political values. Similarly,
health care providers may be reluctant to raise concerns about domestic violence in order to
avoid being seen as an "outsider" or "homewrecker" (Fishwick, 1998). However, as the next
chapter points out, for victims of abuse, especially those who have access to very few resources,
the cost of overlooking this issue is very high.

44

CHAPTER FIVE
Case Study Analysis and Assessment: From Oppression to Empowerment
In a culture of domination everyone is socialized to see violence as an acceptable means
of social control. (hooks, 2000, p. 64)
Failure on the part of the medical system to identify or intervene appropriately in cases
·of woman abuse has many personal, social and economic ramifications, but the most serious
outcome is women's continued victimization and oppression. Women's oppression occurs in a
number of interconnecting ways. Women (and the children who live with them) are
unintentionally victimized by the health care system because undetected abuse can lead to
women not exploring options other than staying with an abusive partner. Because of the cyclical
nature of partner abuse, which usually escalates in both frequency and severity over time,
women could be subjected to continued and more severe forms of physical and emotional
violence (Warshaw, 1994 ). When the violence is not made known, perpetrators are not held
accountable and victims do not receive the support or treatment they need to heal and move
toward safety (Transken, 2002). Undetected abuse often results in repeated health care visits
with vague medical complaints, serious injury or even death (Furniss, 1998). For example, Stark
et al., ( 1979) found that one in five women attending the emergency department had sought
medical attention for abuse injuries at least 11 times previously. Failure to routinely inquire
about abuse means that health complaints can be misdiagnosed, which can translate into
unnecessary surgery, hospitalization and medicalization (Ingram, 1994). In some cases, women
have reported feeling that their safety was jeopardized because the medication they were
prescribed actually weakened their resistance to the abuse:

45

I'm still living with my husband, and I'm afraid that if I take any kind of medication,
that this man is definitely going to have control all over again. So I'm scared, I refused
to take anything ... I know if I take any kind of medication, I won' t be as strong as I am
now .... (McCauley et al. , 1998, p. 553)
Women can also be harmed as a result of receiving poor advice from well-intentioned
practitioners. For example, lack of understanding about the social context of woman abuse leads
some physicians to attribute woman abuse to individual factors, such as substance abuse, lack of
self-esteem on part of the woman and pathology on part of the abuser (Roux & Rittmayer, 1999;
Dr. Paul Herselman, personal communication, November 20, 2002). Insufficient understanding
about how power and control dynamics operate in abusive relationships has resulted in some
practitioners referring their abused patients to couples' therapy (Roux & Rittmayer, 1999).
Studies show that this helping context is actually harmful for victims of abuse because it can
provide a forum for abusers to further victimize their partners (Loue, 2001).

Secondary Oppression: The Isolation Continues
Ann Bishop explains that oppression (such as violence against women) is held in place
by violence in many different forms : "visible, such as injury and death, or less visible, like
exclusion, denial of access and denial of needs" (Bishop, 1997, p. 38). This less visible, but
nonetheless damaging, consequence of an unresponsive health care system is referred to as
secondary victimization. Secondary victimization is a form of oppression that occurs because
women are actually

t

~i

by the negative attitudes of health care workers (Hattendorf

& Tollerund, 1997; Transken, 1995, 2000). Some contend that these negative encounters are, in

essence, a re-enactment of the abusive experience (Warshaw, 1994; Transken, 1995, 2000). In
fact, many women say that the secondary trauma of coming face to face with an unresponsive

46

and blaming "helper" can be more painful and traumatic than the actual violent incident that
preceded it (Hattendorf & Tollerund, 1997; Transken, 1995, 2000). Not surprisingly, a helping
professional who communicates in an unkind, racist or judgmental manner will only cause the
woman to feel a sense of failure, shame and powerlessness. As a result, women who find the
courage to seek help from those who they expect to protect, support and understand them (i.e.,
law enforcement, social services, and health care) often end up feeling betrayed and more
isolated by the encounter (Hattendorf & Tollerund, 1997).
How a problem is framed by major institutions determines the kind of attention it will
receive and the solutions proposed to address it (Kurz, 1997; Mullaly, 1997, 2002). When
woman abuse is seen as an individual, private, family matter rather than a pervasive social
problem affecting millions of women of all backgrounds, it clearly impacts how victims are
perceived and the kind of support they will receive (Warshaw, 1994). Of course, failure by the
medical community to respond adequately to abused women is not a conscious act on the part of
the health care profession. Clearly, most health care workers are genuinely concerned about
their patients and want to help them. As shown, the problem of unresponsive helping is highly
complex. However, what makes it difficult to confront is that it is largely a systemic problem,
stemming from broader ideological ideas about violence against women and reinforced by
institutional constraints that exist within the health care system (Varcoe, 1997; Warshaw, 1994).
According to Varcoe ( 1997), "Violence and abuse are neglected because the power of dominant
interests is exercised through ideologies which are congruent with neglect" (p. ii).
Mullaly (1997, 2002) points out that many people who work in various social
institutions (police, education, social services, health care) unintentionally contribute to and
maintain oppression in simple day-to-day activities, but do not consider themselves to be

47

oppressors (Mullally, 1997, 2002). Mullaly explains how social structures (including the
medical establishment) operate as a major source of oppression, primarily due to unquestioned
norms and underlying assumptions:
The dominant relations of men over women, white people over persons of colour,
affluent people over poor people, heterosexual over homosexual and bisexual persons,
physically able persons over physically and mentally challenged persons have been so
internalized into the structures of society that they have also become intrinsic to the
roles, rules, policies and practices of [social] institutions (Mullaly, 2002, p. 19).
Peggy Mcintosh ( 1989) agrees, saying that people are socialized not to see how class,
gender and race inequities (among others injustices) are systemic problems, not just individual
acts of "meanness." For example, Mcintosh says that white privilege is simply taken for
granted, and refers to it as "an invisible weightless knapsack of special provisions, maps,
passports, codebooks, visas, clothes, tools and blank checks" (p. 10).
Without an understanding about the systemic nature of woman abuse and other social
problems, health care providers will adhere to the same cultural stereotypes and negative
attitudes about victims that are held in society at large and reinforced in the media. Thus health
care providers may hold the view that women abuse is an individual (as opposed to a social or
legitimate medical) problem, leading to victims being held responsible for their victimization.
Others may believe that some women deserve to be abused (i.e., sex-trade workers) or that a
wife's obligation is to be sexually available to her husband at all times (Heise et al., 1999).
Similarly, discriminatory practices may be linked to misconceptions such as the belief that only
poor women or women of certain ethnic or religious backgrounds are victims of domestic
violence and sexual assault ( Heise et al. , 1999). Another common misconception about intimate

48

partner violence is that educated, older and disabled women are not victims of abuse, and
educated, professional men do not abuse their spouses. This physician admits to dismissing the
possibility of abuse in her practice based on these kinds of stereotypes:
I have what I think is a very nice, mostly White, middle- to upper-class practice. Most of
my women are educated .. . I would say that 90% have a college degree. And so, I just
figured it was something I'd never see in my practice. (Roux & Rittmayer, 1999, p. 175)
These attitudes, which play an important role in the labelling and discrimination of
victims of violence along the lines of gender, class and ethnic origin in the health care system,
are the same attitudes that exist within dominant society: a patriarchal, capitalistic and racist
society (Mullaly, 1997, 2002).
Medicine & Patriarchy

From a feminist perspective, patriarchy is central to understanding why women are
mistreated or neglected in the health care system. Many health care practitioners (Muszinski,
1994; Hamilton, 1994) contend that the medical establishment has become highly
professionalized and organized over the years, and this has resulted in a male monopoly over the
practice of medicine. For example, areas in which women held expertise, such as midwifery,
became increasingly under the control of male physicians. Similarly, women were brought into
medicine as subordinate to male physicians through a traditional division of labour. Carol
Baines ( 1991 ) argues that this "sharp division of labour allocated the curing role to men with
women relegated to the maternal tradition of caring" (p. 50). From a feminist lens, this dynamic
is seen as essentially mirroring the sex role division found in the nuclear, patriarchal family. In
other words, the manner in which women are treated in the health care sector does not differ
dramatically from the way they are treated in their home or place of employment. Hamilton

49

(1994) points out that in both the home and work situations, women are relegated to the role of
caregiver, caring for young children, the elderly and the disabled, a role for which they are
seldom financial! y compensated. As a result, Hamilton asserts ( 1994), "women have too often
felt devalued and disbelieved, with our concerns either trivialized or overly pathologized" (p.
60). Others point out that a male-dominated health care system has led to male physiology and
behavior being taken as the norm, resulting in sex bias in research and treatment areas and
women's health concerns not being taken seriously (McBride & McBride, 1994; Jiwani, 1999).
For example, gender differences are shown to exist in terms of the kinds of medical treatment
offered to women, compared to men, such as a tendency to prescribe mood-altering drugs to
women for the same symptoms (Harding, 1994).
Bolaria & Bolaria ( 1994) add to this by stating that, similar to the power structure found
in a patriarchal society, women and racial minorities generally occupy the lowest rungs of the
medical hierarchy. As well as having little input in terms of program, policy and knowledge
creation, they are also often the lowest paid and most highly exploited groups of the health
sector workforce (Hamilton, 1994; Jiwani, 1999). In contrast, physicians, most of whom are
white males, enjoy a higher status and income than all other groups of health care professionals
(Hamilton, 1994). Also, despite increased enrollments of women in medical school, studies

suggest that gender discrimination is still a problem for many women (Kirk, 1994). As this next
section shows, these gender dynamics are also complicated by the biomedical model that is
deeply engrained in the Canadian health care system and reinforced in medical training and
practice (Wuest, 1994).

50

The Medical Model
"A healthy being is more than the sum of its blood/bones/flesh" (Transken, 1995, p. i).
A significant feature of the medical system, and a contributing factor in practitioners'
inability to effectively intervene with victims of abuse, is the medical model. Critics say this
model is problematic because it tends to rely primarily on clinical, mechanistic and
individualistic interventions with patients (Bolaria & Bolaria, 1994; Warshaw, 1993; Varcoe,
1997; Abott & Willimason, 1999; Transken, 2000). Hamilton (1994) argues that instead of
viewing women' s health holistically, the prevailing medical system is based on a reductionist
model of health or model of "biological primacy," in which complex issues are reduced to or
explained as stemming from simple biochemical or genetic factors. Critics of the medical model
point out that this paradigm neglects the importance of social context on health and illness by
separating the mind from the body (i.e., mind/body split) and viewing the body as a machine
(Hamilton, 1994; Transken, 1995, 2000). By focussing more on disease and illness than on
health and prevention, psychological and emotional aspects of healing and psychosocial
contributors to health and illness are neglected. A disease model of health care is problematic,
because it serves to obscure the social nature of disease and fails to recognize the
interconnections between social, economic and political conditions in society, health and illness
(Bolaria & Bolaria, 1994). This means that critical relationships that exist between a person's
health and factors such as gender, class, ethnicity, income levels and geography are often not
considered (Jones & Rothney, _2001; Bolaria & Bolaria, 1994; Hamilton, 1994).

51

The Medical Model and Interventions with Victims of Violence
The medical model, which is based on biological primacy, strongly impacts how
practitioners relate to victims of abuse. Adhering to the medical model means that often only the
immediate physical injuries of physical and sexual abuse are seen, and these are what are
addressed in the health care visit (Kurz & Stark, 1999; Yam, 2000; Transken, 2000). Studies
show that, in keeping with the medical paradigm's values of neutrality, science and objectivity,
physicians are compelled to document incidents of violence using language that focusses
primarily on the physical injury (i.e., hit by fist, blunt trauma) without identifying how the
injury happened. For example, the medical language commonly used in the documentation of
patient records essentially makes the problem of violence invisible (Warshaw, 1993):
Physicians frequently used disembodied language to describe a traumatic event such as
"was beaten to face and head with fist," "blow to head by stick with nail in it," "hit on
left wrist by a jackhammer." What they recorded was the mechanism of injury, how the
blow impacted on the body, not on the person. The entire battering event was reduced to
an interaction between a fist and an eye. (Warshaw, 1993, p. 140)
When attention is given solely to the physical and mechanistic aspects of the violence, it
obscures and discounts the real experience of the person who is receiving help (Warshaw,
1993). The medical model does not see the whole life of the woman before the moment she
attends the emergency department or where she may be going after she leaves (Transken, 2000).
Victims of abuse who are not informed of any other alternatives than living with the violence
will often leave the hospital and go right back into the abusive environment:
They asked me nothing. I told the nurse and I told the doctor. Nothing. Nothing was
said, and I didn't go to a shelter. I went back home after the hospital, limping around,

52

and his father called and asked me, "Just don't leave, please don't leave him." (Yam,
2000,p.467)
The problem with adopting a strictly clinical or reductionist stance with patients is that
in this view illness or social problems are associated with individual lifestyles and behaviors,
which suggests that improvements in health can be restored by changing individual behaviors
(Bolaria & Bolaria, 1994 ). When violence against women is a seen as a problem stemming from
personality or situational factors, it leads workers to conclude that these are the reasons why
women are abused and why they will not leave the abusive relationship (Plichta, 1992). By
adhering to a medical model framework for dealing with woman abuse, the effects of the
violence often become confused with the cause. For example, the woman who uses alcohol as a
way to cope with the trauma of being abused is labelled and treated as an alcoholic. Therefore,
in the words of Kurz and Stark ( 1988), she is viewed by hospital staff as "the problem patient,"
not the "patient with the problem" (p. 265). When woman abuse is seen as an individual
problem caused by something the woman has done (and therefore can change), it perpetuates
feelings of guilt, shame and isolation and increases a woman's dependency on the medical
system. Rather than addressing the root of the problem, which could prevent future injury and
increased use of health care services, the woman becomes dependent on the medical system to
treat (often by way of medicating) her "disorder" (Stark et al., 1979). Ironically, the "frequent
flyer" patient, who is often a product of a medical establishment that does not get to the root of
the problem, is frequently blamed for making excessive demands on the health care system
(Varcoe, 1997; Stark et al., 1979). The labelling process also shapes the way people are
perceived and treated in subsequent health care visits. More than likely, these patients will not
be taken seriously. Smith makes a good point, stating that "once someone is diagnosed or

53

labelled with a mental disorder, the helper no longer expects them to make sense, so people tend
not to listen to or respond to them as if they do" (as cited in Dickinson, 1994, p. 91 ).
Medical training teaches student physicians skills of denial and avoidance in order to
help them effectively cope with the extreme trauma they will be exposed to in the emergency
room (Hamilton, 1994 ). Students who are trained using the biomedical paradigm learn that the
role of communication and empathy is not as important as maintaining an ethic of short -term
efficiency and swift history taking (Hamilton, 1994). This ethic of short-term efficiency is
especially problematic for nurses and physicians treating victims of abuse in the emergency
department. Varcoe (1997) argues that nurses' ability to provide quality care to victims of
violence is seriously compromised because the emergency room setting operates under an
ideology of scarcity, which is complicated by limited resources such as staff shortages and high
turnover. All of these factors contribute to a situation in which providers have less time to spend
with patients and a "controlling ... dismissive and demeaning interview style" (Hamilton, 1994,
p. 62). The process of objectifying also serves to maintain a professional distance between the
patient and the health care provider, making it difficult for the provider to empathize with the
patient.
To summarize, it appears that unresponsive helping on the part of the medical
community is a complicated and multi-faceted issue. However, the way victims are perceived
and treated in the health care system appears to be firmly grounded in an adherence to a medical
model of health care, and is reinforced by institutional constraints (Varcoe, 1997; Warshaw,
1994; Transken, 2000). Bishop ( 1997) asserts that ideological power, or the "power of belief'
makes one group or individual decide what is deemed valuable and possible in our society.
Thus, it becomes easy for institutions to justify maintaining the status quo and not correct

54

discriminatory policies or practices if people buy into the notion that injustice and inequality are
a natural or normal part of life (Bishop, 1997). Feminists (and structural, anti-oppressive,
cultural-studies-oriented social workers) believe that in order to reform institutions and social
practices that encourage, tolerate or enable violence against members of specific groups,
changes need to be made at many levels (Van den Bergh, 1995; DeKeseredy & MacLeod, 1997;
Mullaly, 2002 ; Reinharz, 1992; Varcoe, 1997). Most agree that these reforms must begin with
changing dominant cultural images and stereotypes about violence against women and the day-_
to-day reproduction of dominance through oppressive policies and practices (V arcoe, 1997;
Mullally, 1997, 2002).
Although anti-oppressive or empowerment practice is more commonly associated with
social work practice (Van den Bergh, 1995; Lee, 2000; Mullaly, 1997, 2002) it is increasingly
being applied to a number of other helping contexts, including the health care system (Hotch,
Grunfeld, Mackay, & Cowan, 1996; Hadley, 1992; Rodrigues, 2003). For example, the BC
Centre of Excellence for Women ' s Health is promoting a model of women-centred care that is
participatory, empowering, respectful of diversity, holistic and has a social justice focus
(Rodrigues, 2003). In addition, the health care sector has been increasingly calling for the
development and implementation of anti-oppressive (or empowerment-focussed) research
approaches, practice models and policies in the area of violence against women (Varcoe, 1995,
1997; Hadley, 1992; Archer, 1994; Campbell, 1998; Warshaw, 1994; Hotch, Grunfeld, Mackay,
& Cowan, 1996). Across Canada and the United States, more conferences are being held and
7

more resources and training materials are being developed in order to help practitioners respond
more effectively to victims of violence (Johnson, 2000; Morrow, 2000). For example, Atlanta,
Georgia hosted the 2002 National Conference on Health Care and Domestic Violence entitled

55

"Prevention and Response Strategies: Pushing the Envelope." This conference brought together
over 600 physicians, mental health professionals, dentists, nurses, nurse practitioners, social
workers and advocates interested in exploring ways to prevent and respond to domestic violence
in a health care setting. And of course, another important example of the health care system' s
desire to become more proactive in responding to victims of domestic violence is its adoption of
formal screening protocols to be used in a variety of health care settings, including the hospital
emergency department.
Universal Screening: Setting the Stage for Empowerment
One thing I really remember is that she put her hand on my shoulder. .. She had all this
compassion in her face , and I almost like broke down and cried right then because I was
thinking to myself as she was talking to me "She thinks I'm a human being. She thinks
I'm worth something." (Gerbert, Abercrombie, et al., 1999, p. 128)
Due to the disproportionate amount of health care services used by abused women and
because of its accessibility, many believe that the emergency department is an integral source of
safety and support for victims of partner violence (Grunfeld et al. , 1994; Koss, 1994; Abbott,
1997). Advocates of formal protocols argue that without universal screening it is impossible to
identify those patients who are either past or present victims of violence. Although some injuries
clearly indicate partner abuse, many other injuries and health problems (bruises, migraines,
depression, substance abuse, sleep loss) are less recognizable (Dutton, Mitchell, & Haywood,
1996). By going beyond viewing abuse as a constellation of symptoms, this screening policy is
congruent with the ethics, values and principles of self-determination and human rights that is
the foundation of both social work and health care (Pelligrino & Thomasma, 1988). It is also
consistent with the World Health Organization's definition of health, which is "a state of

56

complete physical, mental, and social well-being and not merely the absence of disease or
infirmity (World Health Organization, 1997).
Earlier it was stated that although all women can benefit from universal screening, this
policy is particularly meaningful for those who have access to few sources of help. For abused
women living with violence in a rural or northern community, the emergency room may
represent a woman's only outside contact (Abbott, 1997). A woman living in these regions may
never have the benefit of meeting with other women in a support group, or going to a transition
house to find out that she is not the only person going through this ordeal. In some cases, the
small community hospital is the only public institution that is likely to interact with all women
at some point in their lives (Derk & Reece, 1989). For this reason, and because of the complex

nature of rural woman abuse, screening for woman abuse in the emergency department could
make a real difference in the lives of women.
However, simply because physicians (or nurses) routinely screen for violence or detect
more cases of violence, the experience will not necessarily be empowering for women. As the
next chapter points out, successful screening is about the process and the quality of the
interaction between the patient and provider, not simply the goal of disclosure. It is only when
patients feel heard, believed, validated and informed that providers can pave the way for
empowerment to begin (Warshaw, 1994). In order to explain how a policy of universal
screening has the potential to empower women, a definition of empowerment will be provided.
Following this definition, I will demonstrate how the principles of empowerment can be used to
enhance the screening process.

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CHAPTER SIX
Empowerment Approach to Helping Abused Women in the Health Care Encounter
Since all forms of oppression are linked in our society because they are supported by
similar institutional and social structures, one system cannot be eradicated while the
others remain intact. (hooks, 1984, p. 35)

Empowerment Defined
The Social Work Dictionary defines empowerment as "the process of helping
individuals, families, groups, and communities increase their personal, socio-economic, and
political strength and develop influence toward improving their circumstances" (Barker, 1999,
p. 153). As an integrative framework for practice rather than a particular theory, the
empowerment standpoint is multi-focussed (Lee, 2001). This approach addresses both clinical
and community-oriented holistic work with individuals, families, small groups, communities
and political systems. As such, it is an ally to many social work practices and frameworks
including feminism, structural and anti-oppressive social work, interactionism, constructivism,
cultural studies and liberation theory (Lee, 2001 ). This perspective is strongly influenced by
Germain & Gitterman' s ( 1980) "life model" of social work or ecological approach. Ecology is a
metaphor used to describe the continuous reciprocal exchanges (or transactions) in which people
(organisms) and environments influence, shape and, at times, change each other (Germain,
1991 ). This is a strengths-based and action-oriented approach as it recognizes that human beings
strive to achieve the best "person-in-environment" fit possible between their needs, rights and
capacities (Germain, 1991 ). By extending the ecological model, an empowerment orientation
recognizes that stigmatized people (northerners, immigrant women, Aboriginal women, gay
people, poor people, the disabled, and so on) seldom achieve a "good fit" in their environments

58

because they are faced with social, political and economic discrimination which "stifles human
potential" (Lee, p. 24). What makes an empowerment approach meaningful is its ability to see
that marginalized people are often overlooked in mainstream social work practice because
change is typically directed at the personal or family level, and because traditional practice tends
to be colour blind (Mullaly, 1997, 2002). In short, empowerment social work is committed to
understanding the nature and dynamics of oppression, how social and political functions are
carried out in the best interest of the dominant groups, the effect it has on the oppressed and how
people cope or resist their oppression (Mullaly, 2002).
According to Burstow (1992), oppression, lies and isolation all work together to alienate,
confuse and disempower people. For empowerment to occur, therefore, people will need to
develop an awareness in order to cut through the lies and confusion, and rid themselves of their
internalized oppression. According to Paulo Freire's liberation theory, "critical consciousness
and knowledge of structural inequalities and oppression are power" (Freire, 1970, p. 12).
However, action, both individually and collectively, is as important to the process of
empowerment as is critical reflection. This means that while individual helpers can facilitate
empowerment, the process is most meaningful when people have an opportunity to connect with
other members of their oppressed group. The benefit of connecting with other people in similar
circumstances is that it not only breaks down the alienation they experience, but it also fosters
mutual support and stimulates common analysis and further action (Burs tow, 1992).
As mentioned, it is often a lack of awareness and education around the subject of woman
abuse that sets the stage for inappropriate or unresponsive interventions with abused women
(Ingram, 1994 ). However, before health care workers or other helpers are in a position to
empower abused women, they need to first develop their own critical consciousness about the

59

issues facing abused women. For the intervention to be empowering, education and training
need to be aimed at physicians gaining a better understanding of the broader social implications
of violence against women, as well as the physical and emotional consequences of woman
abuse. This section will explore these areas in more depth.
Developing a Critical Consciousness: Seeing the Bigger Picture
At a broader level of analysis, for empowerment to take place in the health care
encounter, there must be an attitude shift in which violence against women is seen not simply as
a series of isolated cases of violence, but a pervasive social phenomenon (Warshaw, 1994).
Being critically conscious means that workers are especially sensitive to the broader social
issues that operate to disempower vulnerable groups of people (Lee, 2001 ). Whether a person
works in an urban or rural setting, an integral part of an empowerment-based helping approach
is being aware of all aspects of a person's environment or having a multi-focal vision.
Practitioners committed to a multi-focal vision will need to put the history of a group's
oppression under a microscope (Lee, 2001). The goal is to make sure that people' s personal,
private struggles are linked to the structural source of their troubles (Land, 1995; Mullaly,
1997). As such, all social problems are not viewed solely as individual, family problems but are
viewed with a historical/social/cultural lens. When workers use this lens, they are able to see
that high incidences of woman abuse or other issues such as suicide, depression and substance
abuse are not characteristics of a particular group (i.e., northern residents, poor people,
immigrant women, First Nations women, and so on). Rather, workers know that these are
outcomes of oppression-a condition that comes with patriarchy, capitalism and racism
(Burstow, 1992; Arges & Delaney, 1996; Mullaly, 1997). Furthermore, a multi-focal
perspective brings a greater appreciation for how the effects of violence are more profoundly

60

felt by those who are socially marginalized (the disabled, elderly, immigrant and refugee women
and First Nations women, for example) (Morrow, 2000). More specifically, workers providing
support to abused women in the north need to possess knowledge of abuse in general, but they
also need to be sensitive to the unique elements that make life challenging for women
experiencing violence in this context. These include the elements of northern life that shape
women' s experiences with violence, such as the sociological, psychological, cultural and
economic factors of isolation, patriarchal family structure, the implications of religious and
cultural beliefs and inadequate social and health services. Being sensitive to the issues which
shape the north also requires understanding how the north is historically characterized by
colonization, exploitation and social and economic inequities (Arges & Delaney, 1996).
Once practitioners develop a critical consciousness, they are then in an ideal position to
share this information with their patients, allowing patients to gain new insight into their
situation. Most notably, these new insights help to break down the stigma, shame and
internalized guilt that comes with being a member of an oppressed group. Paulo Freire ( 1970), a
well-known Brazilian educator, believed that as people begin to visualize themselves as creators
of their own culture, they may realize that they were not destined to hold an inferior class status
but that their status is determined by broader economic-political-ideological conditions.
According to Varcoe ( 1997), critical reflection is the key to changing neglectful practices with
victims of abuse:
When individuals practice in resistance to dominant ideologies, collective
practices that challenge unequal power relations are promoted. With regard to
violence and abuse, such resistance can create collective practices that can
contribute to ending violence and abuse. (p. 353)

61

As individuals become more critically conscious about partner violence, the collective
practices of other physicians and nurses in the hospital setting could be impacted (V arcoe,
1997). This could then have a positive influence on other helping institutions and the
community at large. For example, by regarding woman abuse as a legitimate medical and public
health concern, the medical community could use its authority to draw more public attention and
sympathy and attract public funding (Findlay & Millar, 1994). Publicly declaring that violence
is unacceptable may have a significant impact in smaller communities where the conspiracy of
silence can be even more pervasive. Given that physicians are usually held in high esteem in
smaller communities, their influence in community programs regarding health care issues may
be viewed highly (Fishwick, 1998).
In addition to developing a critical awareness about the broader issues affecting people
seeking help, physicians and nurses need to possess a thorough knowledge of the complex
dynamics of violence against women, as well as the health-related consequences that stem from
violence.

Education About the Dynamics of Woman Abuse and Health Consequences
She'd rather have him beat her up once in a while but still provide food and shelter.
(Roux & Rittmayer, 1999, p. 177)
Health care professionals can only begin to help women become empowered once they
have a thorough understanding of the physical, sexual, psychological and spiritual forms of
abuse women experience. 5 Providers should be aware that most victims of violence first seek
medical help for secondary causes of violence rather than for the initial abuse-related incident
(Koss, 1994). This requires doctors to be cognizant of the common violence-related health
concerns raised earlier in this paper, such as anxiety, hypertension, depression, migraine

62

headaches, addiction issues, gynecological problems and sleep disorders (Heise, 1994).
Physicians should also be aware that abused women are particularly vulnerable during and after
pregnancy (Abbott & Williamson, 1999). Finding out which stage the abusive relationship is at
is essential, as treatment will vary according to whether it is a case of chronic, lifelong abuse
versus a recent violent episode in which the woman may be suffering from post -traumatic stress
disorder (PTSD) (Dutton et al., 1996). Furthermore, it is essential that physicians know that it is
common for partner violence to get more severe over time.
Gaining critical insights into the complexities surrounding the issue of woman abuse
benefits individuals, health care professionals and communities at large. After consciousnessraising, dialogue aimed at helping victims find their own voices is the next most important
feature of empowerment practice (Lee, 2001). As this upcoming section will demonstrate,
universal screening is a forum in which this dialogue can take place.

The Primary Goals of Universal Screening
Many universal screening tools are available for use in a variety of health care settings.
However, the screening policy presented in this paper comes from the Domestic Violence
Intervention Program developed by the Vancouver General Hospital (Hotch et al. , 1995). Based
on the guidelines offered by the American Medical Association ' s Report on Violence Against

Women: Relevance for Medical Practitioners, the Vancouver General Hospital implemented its
own domestic violence screening program in 1992. Four recommendations put forward in that
report were incorporated into the Vancouver General Hospital screening policy. The following
have been developed specifically to assist physicians in providing quality, compassionate care to
abused women:

63

1. Routinely incorporate screening to identify female patients who are or have been victims
of violence
2. Validate the woman's experience of victimization and recognize symptoms as possible
causes of violence
3. Record patient victimization histories
4. Refer patients to appropriate medical or health care professionals or community-based
resources as soon as possible (Hotch et al., 1995)
I have chosen to use this screening tool in this paper for a number of reasons. First of all, it is
the policy being used (albeit informally) in many BC hospitals. Second, the benefits of this
screening policy have been documented. The staff estimate that the number of documented
cases of domestic abuse has doubled since its inception, and the feedback from the staff has
been positive (Ministry of Women's Equality, 1999). Finally, and most importantly, the
principles of this screening program reflect feminist/empowerment principles. For example, the
training guidelines highlight the significance of changing dominant ideology (i.e., myths
regarding abuse victims), screening every woman, respecting choices, validating women's
experiences, empowering women by raising their consciousness about the violence, and offering
valuable information and resources (Jiwani, 1999). The purpose of this next section is to look
more closely at how the four steps of universal screening are put to practice with an emphasis on
how they have the potential to empower patients. Particular attention is given to how this
process may impact patients and practitioners in rural, northern and remote communities.
Step 1: Routine Screening and identification
As discussed above, the fact that the health care community has not been responsive to
the needs of abused women is largely due to the education and socialization process within the

64

medical establishment and not because helping professionals consciously choose to ignore the
needs of certain populations. The purpose of an empowerment approach is to fill that gap by
ensuring that the needs of all oppressed populations are addressed (Lee, 2001 , p. 48). Being
asked about abuse does not have a negative impact on those who are not abused, but it could
make a difference for a woman who is. Therefore, the first objective of universal screening is to
ensure that all women are asked about violence regardless of their history with violence or
presenting injury. To be clear, it is not enough to informally adopt a screening policy. Universal
screening has to be a formal protocol that ensures all women patients are questioned upon
entering the emergency department. While most physicians are good at detecting cases of
obvious physical violence, many do not recognize that other symptoms or stress-related
problems could be violence related (Rodriguez et al., 1999). Therefore, screening helps alleviate
the risk of missing someone whose injuries are not visible and identify those who may be
reluctant to disclose without direct questioning (Dutton et al., 1996).
An important aspect of routine screening is that by telling patients that all women are
being asked about woman abuse, health care providers demonstrate the magnitude of the
problem to the patient. When women believe that they are a very tiny minority of women being
affected by this issue, they believe they must be doing something to deserve the violence
(Mullaly, 1997). As such, screening all women regardless of age, cultural or socio-economic
background, ability or sexual orientation reduces the chance that only certain populations are
singled out and challenges myths about certain groups being more prone to violence than others.
Knowing that all women are being asked about abuse might also help women feel less alone in
their situation. In other words, the screening process allows the health care provider to
normalize the experience for patients, which in turn helps to reduce the internalized blame, guilt

65

and stigma. By asking all women, screening also gives providers an opportunity to intervene at
different stages of relationship violence: current, past and possible future abuse. Physicians who
uncover abuse are able to intervene at the secondary and tertiary levels (i.e., tend to the
immediate effects of abuse and long-term effects of abuse), but screening also has a preventive
element to it. This means that screening provides staff with an opportunity to intervene before
the cycle of violence even begins, which is particularly salient for teens who may be involved in
a violent relationship (Dekeserdy & MacLeod, 1997). Another potential benefit of screening is
that women who are asked about abuse in a health care visit could then share this experience
and knowledge with other women, some of whom may be victims of abuse themselves (King,
1998).
Why Language is important. Although screening in a busy emergency room requires the

physician to be brief and direct, it can still be conducted in a respectful and caring manner.
Concern can be demonstrated through words as well as through attentive body language and
reflective listening (Gerbert, Abercrombie, et al., 1999). By believing the woman and being
open to discussing the issues, the health care provider may set the stage for the woman to feel
safe enough to break the silence and reach out for help. It is important to note that this could be
the first time the woman ever told anyone about the abuse (particularly in a smaller community).
For the woman in this interview, speaking out about the violence was the first step in her
decision to leave her abusive spouse:
It was a relief to be able to tell someone, and I actually think [laugh] that was the
beginning of the end of our marriage ... and I think what started the wheels turning in my
head, that I could get out of this and I should get out of this . . .if I tell someone that my

66

husband's breaking my bones, it's time to leave. (Gerbert, Abercrombie, et al., 1999, p.
127)
As the next section shows, screening questions can be framed in a way that reflects
concern for the patient's well-being and a willingness to talk about the violence.

The questions. The following is a list of questions that I have adapted from the Vancouver
General Hospital Domestic Violence Guide (Hotch et al., 1995). These are simply guidelines;
the exact wording is not as important as making sure that every woman is asked and it is done in
a non-judgmental and sensitive manner. However, it is important to pay attention to language, as
some questions could unintentionally re-victimize the woman by suggesting that she is to blame
for the violence.
When there are no obvious injuries a provider may say
•

From my experience here in the emergency department, I know that abuse and violence at
home is a problem for many women. Is it a problem for you in any way?
When there are obvious injuries, a provider might ask

•

The injuries you have suggest to me that someone hit you, is that possible?

It is important not to neglect the possibility of emotional abuse and sexual abuse.
Establishing good rapport with a patient is necessary before asking about sexual abuse:
•

Does anyone call you names, criticize you or insult you?

•

Does anyone monitor what you are doing, prevent you from seeing people or going to work,
or withhold money from you?

•

Have you ever been forced to have sex with your partner when you did not want to?

If the screening process reveals abuse of any kind (physical, sexual or emotional), a more
complete assessment is then carried out. It should address the following areas: the nature and

67

details of the abuse (i.e., the date, time, and circumstances of the incident), previous assaults and
resulting injuries (Loue, 2001). The following are important questions as they reflect the
seriousness of the abuse and the risk of danger:
•

When was the last time you were abused. What happened? What did he do/say?

•

How often does the abuse occur?

•

What events preceded the violence?

•

Is the abuse getting worse? More frequent?

•

Has your partner ever threatened you? Has he ever used a weapon?

•

Are you afraid of your partner? Are you afraid for your life or for the lives of your children?
Key message: The violence is not her fault. One of the most important functions of

universal screening is that it provides practitioners with an opportunity to reassure women that
the physical, sexual and emotional abuse they have endured is not their fault. Physicians and
nurses who are cognizant of this will be less likely to attribute the woman's symptoms to
something she has brought on herself (Warshaw, 1994). Additionally, a woman's sense of selfblame can be lessened when she understands that the depression and other stress-related
problems she may be experiencing are normal reactions to living with violence (Land, 1997).
On the other hand, practitioners can unwittingly re-traumatize a women by asking her questions
along these lines: "why did you go there with him?" or "why don't you just leave him" (Archer,
1994 ). Similarly, screening questions should avoid stereotypical or stigmatizing language
(Dutton et al., 1996). Some abused women report that the words used by their health care
providers impacted how they viewed their situation and what steps they took to change it
(McCauley et al., 1998; Warshaw, 1993). Asking a woman if she is a "battered woman" or a
"wife-abuse victim" is not going to facilitate disclosure, as these terms do not accurately

68

describe the experiences of many women who are in violent relationships. For example, many
women will not see themselves as battered because they may not have sustained physical
injuries. As well, it is important to realize that denial and minimization of the violence are
common coping strategies for many abused women; thus, asking a patient is she is an abused
woman will not likely facilitate disclosure. An empowerment model reflects a move away from
a disease model of intervention, which sees abused women as sick, deficient or passive, to a
view of women as survivors. Stated another way, empowerment practice sees abused women
seeking help "as victors not victims" (Lee, 2001, p. 60). Workers need to realize that many
abused women, despite living in a climate of fear, often make frequent attempts to flee their
abusers and protect their children. Studies attest to this fact, showing that women are not passive
but actively work to make their environments safer. Bowker's (1986) study of 1000 abused
women suggests that the reason it takes women so long to leave is not from passivity but is a
testament to the abuser' s persistence to maintain control and domination and to a lack of support
from social institutions.
Understandably, as physicians and nurses become more critically conscious about the
issues surrounding violence, they are going to develop more concern and empathy for their
patients (Warshaw, 1994). Where there is empathy, there is genuine concern and compassion,
and these are the main ingredients of an empowerment perspective of helping (Lee, 2001).
Studies reveal that some survivors of violence feel that being asked about the violence in a
compassionate manner provided validation and even helped them move toward safety (Gerbert,
Abercrombie, et al., 1999). Validation plays an integral role in the empowerment process and is
an important element of a universal screening protocol.

69

Step 2: Recognizing Symptoms and Validating Women 's Experiences
Recognizing symptoms. Understandably, there are serious physical injuries (broken
bones, lacerations, bums and so on) that accompany violence that require immediate medical
attention. As mentioned, the benefit of screening is that it may uncover those aspects of abuse
that may otherwise go undetected because the symptoms are not always visible. Domestic
violence guidelines encourage physicians to be suspicious of abuse in cases in which the woman
has headaches, non-specific pain, sleep disorders, anxiety, dysphasia or hyperventilation. As
stated earlier, these health concerns, as well as substance abuse problems and various
gynecological and reproductive problems, are all indicators of possible abuse (Loue, 2001 ).
Validation. For some women, simply being asked about abuse and being reassured that
the violence is not their fault can bring about a sense of relief, comfort, validation and in some
cases facilitates the leaving process (Gerbert, Abercrombie, et al., 1999). The woman in this
interview reveals how information and validation from a health care provider "planted the seed"
for leaving her abusive partner:
And after they sat down and said no, I was not the one that was causing it, nobody
deserves to get hit. ..The doctor told me that, and the deputy told me that. That I don't
deserve to be hit. .. I don't have to stay there, and that there's other ways of dealing with
it. And I'm sitting there listening to these people saying these things to me, and I say,
"oh, okay!" .. . it's like a seed was planted. (Gerbert, Abercrombie, et al., 1999, p. 128)
Accepting that planting a seed is all that the screening process might accomplish may be
difficult for health care professionals to accept, given that they are used to diagnosing, treating
and curing medical problems. Practitioners who want to empower victims of abuse will need to
make every effort to diminish the power dynamic that typically characterizes the physician-

70

~

~

patient relationship. By seeing women as experts on their own lives and circumstances,
practitioners who are committed to empowering women will respect all of their choices. Even
though they may be treated in a sensitive manner, some women will choose not to discuss the
issues, access supports or leave their abusive partner. As stated, the primary goal of screening is
not to get more women to disclose abuse, but to give them the option to do so (King, 1998).
One of the most important objectives of screening, regardless of a woman's choice, is
that she hears that the violence is not her fault. While the woman may not be in an emotional or
financial position to leave her partner at the time of screening, she may be at a subsequent visit.
By helping her let go of the blame and shame surrounding the abuse, her self-esteem may
improve; this could then give her the inner resources she needs to re-evaluate her situation and
deal with it in a more effective way (Mullaly, 1997). It is important to realize that individual
empowerment is rarely "a linear, forward moving, and uninterrupted journey" (Mullaly, 2002, p.
215). Some women report that their ability to successfully leave an abusive relationship is
attributed to learning about themselves, the truth of their victimization and the batterer's
responsibility for the violence (Ulrich, 1991 ). Knowing that this is a long-term process for many
women raises some serious safety issues, particularly for northern women.
Paying attention to safety, privacy, and confidentiality. Ensuring the woman's safety is

essential in the screening process. It is imperative that screening not increase risk to the patient.
Privacy is necessary in order to ensure confidentiality, but most importantly, to protect women
from repercussions from an ab.usive partner (Dutton et al., 1997). As mentioned, ensuring
privacy and confidentiality is even more of a challenge in a smaller hospital setting. However,
every effort should be made to ensure that screening protocols are conducted privately and away
from those who may have accompanied the woman. Disclosure is unlikely if the woman can be

71

heard or believes she can be heard. During the screening process, physicians and nurses must
carefully assess a woman's immediate safety, particularly if her abusive partner brings her in.
Clearly, breaking confidentiality could put a woman' s (and her children ' s) safety in serious
jeopardy (Ingram, 1993). Furthermore, breaching confidentiality by taking action without her
consent (i.e. , calling a transition house, counsellor, etc.) is also disempowerng for women.
Making choices without a woman's consent takes away her control over the situation and fosters
feelings of dependency and powerlessness (Dutton et al. , 1996).

Step 3: Recording Patient Victimization Histories
Documentation is an important consideration so that future physicians and nurses can
help patients who return after another incident and also for legal purposes and custody issues.
Recording the abuse also shows women that their concerns are being taken seriously.
Documentation may include recording a detailed description of present and past abuse including
photographs and/or a body map of any injuries (Plitcha, 1992). From an empowerment
perspective, use of language is important. Documentation should clearly state how the injuries
were sustained. Recording comments such as "hit by fist" neglects the broader context of who
was hit by whom. Also, practitioners who are committed to empowerment principles believe a
woman's story. This can be reflected in the language used in medical files. Brockmeyer &
Sheridan (1998) caution against using phrases such as "allegedly beaten by boyfriend" or
"refuses to go to transition house" (p. 222). These comments are not only disempowering to the
woman, but they also question her credibility, which can be harmful to her if the file is later
used in court.

72

Step 4: Referring Patients
Women can be empowered simply by increasing their knowledge of and access to
resources such as the legal system, shelters and support groups (Dutton et al., 1996). Given the
busy nature of an emergency department, it is not possible for physicians and nurses to engage
in long counselling sessions with patients. Clearly, hospital-based social workers have an
important role to play after a patient has disclosed abuse. Whoever is working with the patient,
whether it is a health care provider or social worker, needs to be familiar with several
community resources and referrals so that abused women can access them immediately or at a
later time. To adequately serve the needs of abused women, partnerships need to be made
among all helping agencies in the community: the hospital, social services, the police, crown
counsel as well as community groups (transition houses, women's centres, multicultural services
and so on). Health care providers can supply a woman with a package of educational materials
or a card with important contact numbers, such as crisis lines, shelters, legal services, women's
centres and so on. For example, a women's support group can be a particularly powerful forum
for women to connect with other women who are going through similar circumstances and to
validate each other, while at the same time working toward alleviating the isolation, stigma and
shame (Burstow, 1992).
While urban-based physicians may be able to refer patients to a hospital social worker,
transition house or women's support group, rural- or northern-based physicians often do not
have these services at their disposal. Because physicians working in isolated regions typically
have limited referral options, they may have to be more active in terms of providing supportive
counselling, problem solving, safety planning and follow up (Goeckermann et al., 1994 ). In
rural areas, the physician may be an abused woman's primary source of help for an extended

73

period until she can get in touch with other resources, which may be many miles away. If there
is no transition house available and the woman has no other safe place to go, sometimes an
extended hospital stay may be necessary. In the United States, some hospitals have established
safe-rooms for women whose physical safety is at risk (Loue, 2001).
Clearly, this health care policy has a more direct impact on health care workers than
social workers. The goal of the next section is to describe how this policy is relevant to social
work. It will show that whether or not social workers provide direct services to abused women,
the subject of universal screening for violence in a health care setting is still a matter of
considerable interest for the profession of social work. Given the personal, social and economic
costs of violence against women (Koss, 1994; Day, 1995), implementing a screening policy that
contributes to the intervention and prevention of woman abuse impacts all members of society:
individuals, families, governments and all sectors of the helping community.

74

CHAPTER SEVEN
Implications for Social Work
Affirming that violence against women constitutes a violation of the rights and
fundamental freedoms of women and impairs or nullifies their enjoyment of those rights
and freedoms , and concerned about the long-standing failure to protect and promote
those rights and freedoms in the case of violence against women. (Declaration on the
Elimination of Violence Against Women, United Nations, 1994)
The first and most significant reason that screening for abuse is relevant to social work is
that violence against women in relationships is a global social problem that represents a
violation of basic human rights and a barrier to social justice (World Bank, 1997). All social
workers have a responsibility, according to the Canadian Association of Social Work (CASW)
Code of Ethics, "to advocate change in the best interest of their clients and for the overall
benefit of society, the environment and the global community" (Westhues, 1999, p. 237). Social
work as a profession is also committed to "the elimination of discrimination; equal distribution
of resources; advocacy for a clean and healthy environment; and the promotion of social justice"
(Westhues, 1999, p. 237). Clearly, understanding the implications of social policies and
advocating for policies that promote social justice is a central feature of social work practice.
Whether the focus of a policy is on the international, federal, provincial, local or agency level,
social workers' understanding of an involvement in policy development benefits clients, their
families and communities (Westhues, 1999). Graham, Swift, & Delaney (2000) agree, stating
that participating in social policy development allows social workers to tune in to the realities of
the people they serve. They state: "knowing the circumstances under which many of our clients

75

live, we can become proponents for policies that will enhance their well-being and advocates
against policies that negatively affect them" (p. 15).
Discipline-Jumping

While this case study examines a policy that directly impacts health care practice, social
workers and other helping professionals have an important role to play, particularly in northern
communities. For hospital-based social workers, involvement may take place in a number of
capacities. This might involve providing training and education on the dynamics of abuse to
staff, assisting in both the development and delivery of the policy and offering counselling
support to victims (i.e. , patients may be referred to the social worker) (Shields et al. , 1998).
Small, northern or rural hospitals do not always have the benefit of having social workers to call
on. Despite this, many opportunities still exist for social workers to partner and share the burden
of care with health care practitioners by contributing to the development and implementation of
a screening tool and offering support to women in the community (Johnson, 2000; Shields,
Baer, Leininger, Marlow, & DeKeyser, 1998). In fact, working collaboratively and making
partnerships with all members of the professional helping community Uustice system, social
services, mental health, health care, etc.) is the most effective way to address social issues in
northern communities (Arges & Delaney, 1996). In order to promote local control and
empowerment, multi-disciplinary practice must involve building bridges with both formal and
informal (natural helping) sources of support from the community (Delaney, 1995). Being
responsive to northern communities means that social workers and other practitioners work with
their communities, as opposed to working in their communities (Delaney, 1995). According to
Arges and Delaney (1996), the best way to accomplish this is to adopt a polycentric or cultural
studies perspective. As mentioned, a cultural studies perspective is one which uses a multi-focus

76

and anti-discipline approach, which makes its primary focus understanding and changing the
"structures of dominance everywhere" (Sardar & Van Loon, 1998). 6 The point here is that
understanding and changing structures of dominance (i.e., oppressive practices, policies or
ideas) is not confined to the domain or territory of one particular discipline (medicine, law,
education, psychology) or agency such as social work or health care (Transken, 2002). To the
contrary, intervening in issues such as woman abuse, criminal harassment and other social
injustices benefits from a discipline-jumping approach (Transken, 2002). This is particularly
relevant in northern communities where both health care and social work operate as generalists
and both operate from similar professional principles. More specifically, violence against
women is a matter of interest to any profession that is concerned about the well-being of
vulnerable populations and is committed to values of social justice, autonomy and beneficence
(Warshaw, 1994).

77

CHAPTER EIGHT
Evaluation of the Policy and Future Research Recommendations

Equality for all women will come about only as these attitudes, imbedded in the
workplace, educational institutions and the family, are challenged and begin to change.
To achieve true equality, actions must be taken that adjust for the differences in
experiences and situations between women and men, and among women, and that
correct the systemic nature of inequality. (Status of Women Canada, 1995, p. 14)
The previous chapter highlighted some of the practice implications for screening for
woman abuse in a health care setting using an empowerment framework. The purpose of this
chapter is to present an evaluation of this policy and to offer some suggestions for future
research regarding woman abuse and screening in northern, rural or remote health care settings.
Potential Challenges of Universal Screening
I have already explored some of the obstacles found in the literature regarding health
care workers' abilities to effectively intervene in cases of domestic violence. I have indicated
that implementing a formal screening policy in rural areas will have its own set of distinct
challenges. Although I believe that the benefits of screening certainly outweigh any
shortcomings it may have, there are some additional side effects that are worthy of mention.
First of all, because this idea is relatively new, there are no studies available that address
the feasibility of universal screening. However, it is likely, particularly in the short term, that
screening could have an impact on the hospital staff (i.e., social workers, physicians, nurses and
specialists) with regard to increased time and resources needed for training, screening and
intervening. In addition, as more violence is detected, screening could lead to more women
seeking secondary sources of support from various helping institutions, such as the police,

78

transition houses, support groups, mental health services, legal services, social services and so
on. However, I agree with proponents of screening who point out that the long-term costs
(personal, financial, social and economic) of not intervening in cases of domestic violence are
much higher than the costs of developing and implementing a tool that could potentially
interrupt the cycle of violence (Warshaw, 1994).
Along the same lines, some critics argue that routine screening should not be done
because there is little evidence that screening is helpful to clients or that it actually prevents
violence (Cole, 2000). A comparison of screening tools goes beyond the scope of this paper, but
researchers have explored the efficacy of some protocols.8 The position taken in this paper is
that success in screening for violence in intimate relationships cannot be measured the same
way other screening practices can (e.g., for cancer or diabetes) (Gerbert, Abercrombie, et al.,
1999). The preventive qualities of screening are difficult to assess. Screening may be the
catalyst for a woman who leaves an abusive partner, or it be one of many factors contributing to
her decision-making process. It takes most women a long time and several attempts before they
feel they can safely leave an abusive relationship (Bowker, 1993; Warshaw, 1994). However,
though the benefits of screening are not always visible to the health care practitioner, it does not
mean the intervention is not worthwhile.
Another limitation of this screening tool is that achieving true universal screening is
difficult, even where hospital staff supports the idea and recognizes the seriousness of the
problem (Grunfeld et al. , 1994). The nature of a busy emergency room department means that
even when there is a formal screening protocol in place, it is still not always possible to screen
every patient who comes through the door. Screening policy evaluations indicate that those who
fall through the cracks are patients who come in to the emergency department by ambulance, or

79

those individuals who are intoxicated, hostile or seriously ill. Screening is also not easily carried
out with women for whom English is their second language, such as immigrant women or
refugee women (Grunfeld et al., 1994 ). Screening patients who do not speak English is
problematic in urban settings, and this would undoubtedly present a greater challenge in a
smaller community where access to interpreters is even more limited. However, one of the
primary tenets of empowerment practice is ensuring that vulnerable people (e.g., women who
have limited English language skills) do not fall through the cracks in the screening process . .
This means that every effort should be made to ensure that all women have a voice in the
screening process (and in all health care visits), either through face-to-face or phone translation
services.
There are also problems that come with asking about violence at a triage desk, in both
urban and rural settings. Triage desks offer limited privacy and confidentiality, and given how
brief the screening process is, fostering rapport could be difficult, particularly in smaller
communities. To be sure, practicing in northern, isolated regions, whether it is social work or
health care, often requires innovative and creative strategies to overcome these kinds of
obstacles. What is clear is that working collaboratively and creating networks of support with
other agency workers from the social service, mental health, justice and health care sectors,
seems to offer the most promise for effectively addressing social problems such as woman
abuse (Morrow, 2000; Shields et al. , 1998). Urban-based social policies are generally a poor fit
for rural settings (Delaney, 1995). In order for a screening tool to be truly effective in a
northern, rural or remote health care setting, it will have to be tailored in a way that reflects the
unique qualities of the particular community. Furthermore, practitioners who want to implement
a screening policy in a northern health care setting will be required to seek out allies in the

80

community (including survivors of abuse) who are also committed to addressing the issue. One
effective way of doing this is to build on the strengths of self-help and informal helping
resources that are already present in the community (Fuchs, 1997). Building bridges with
community members and agencies is imperative in order to share the burden of care (Johnson,
2000) that comes with the training, education and development needed to implement a screening
protocol. An example of this kind of partnership approach to addressing woman abuse can be
found in Fort St. John, BC, where collaboration took place between the Fort St. John Hospital
Emergency Department, the Specialized Victim Assistance Program and the Sexual Assault
Centre. Working together, this team developed innovative fundraising techniques which led to
the creation of a hospital-based sexual assault service (Morrow, 2000).
Finally, I recognize that universal screening is a micro-level policy that may limit its
ability to affect the broader structural changes that are needed to truly eliminate a pervasive
social and political problem such as violence against women. Women ' s continued victimization
is linked to national and provincial social policy issues such as poverty, unemployment,
education and housing as well as broader structural issues of racism, patriarchy and capitalism.
Clearly, universal screening is not a panacea. However, this policy represents only one
component of a number of micro- and macro-level initiatives needed to address a problem of
this magnitude. Addressing this problem adequately requires the coordinated efforts of
individuals, communities, agencies and governments to prevent it from becoming another BandAid or ad hoc approach to addressing social problems. However, because universal screening
has the potential to break the cycle of violence, I agree with Mullaly ( 1997, 2002), who points
out that policy and practice strategies that are directed at both the personal and the political level
have an equally meaningful role to play in creating a socially just society.

81

Future Research
While preparing this case study, a number of potential topics of research were brought to
my attention. For example, some health care practitioners recommend that longitudinal studies
be carried out in order to determine whether screening tools have the potential to prevent future
episodes of violence and injury (Cole, 2000). Similarly, while many argue that screening should
be done, it is not clear what is the best way to do this. Some call for more evaluations to be
carried out on screening tools in order to make them more precise and promote better uniformity
(Larkin et al. , 1999). In addition, there appears to be a gap in research with respect to costeffectiveness of screening for woman abuse. This knowledge is important because it could help
guide policy makers, providers of funds and activists in demonstrating feasible interventions for
most effectively addressing violence against women (Garcia-Moreno, 1999).
Although there is a great deal of discussion about efforts to improve health care response
to abused women, most of this literature pertains to urban populations. It appears that no models
of universal screening have been developed for rural areas, and few articles have been written
that address the unique challenges facing practitioners in these areas (Johnson, 2000). Jiwani
(1998) and Websdale (1998) recommend using qualitative methods as opposed to quantitative
approaches in northern or rural communities. They argue that research development (as well as
practice and policy development) is most beneficial to northern communities because it can
draw on the expertise of local residents and practitioners. I would add to this that feministoriented, qualitative studies (participatory action, ethnographic or phenomenological) are also
ideal ways to explore sensitive topics such as violence against women. More specifically, few
studies have explored the factors that contribute to abused women's helpful encounters with
health care workers (Gerbert, Abercrombie, et al., 1999). Therefore, using a qualitative

82

approach that allows women (including "differently situated" women) to share what they
perceive as helpful encounters with health care providers could benefit those who are trying to
develop screening protocols in these areas. However, because few data exist on the prevalence
of woman abuse in rural areas, quantitative studies (i.e., surveys) have an important contribution
to make toward enhancing our understanding of the scope of this problem in northern
communities. With evidence showing that partner violence is a significant problem for women
residing outside urban centres, there may be a greater willingness and cooperation on the part of
the health care sector and the broader community to implement programs and services to
address this issue.

83

CHAPTER NINE

Summary and Concluding Comments
Never doubt that a small group of committed citizens can change the world. Indeed, it's
the only thing that ever has. (Mead, 1928)
Violence against women in relationships represents a significant public health concern
and human rights violation. All individuals, communities and agency workers have a role to
play in eliminating this problem. One of the major reasons that woman abuse continues to be
pervasive today stems from the fact that society collectively permits it to occur, through its
silence and failure to respond adequately to victims in need of support (Loue, 2001). In recent
years, many have argued that the health care sector is ideally positioned to help in the
intervention and prevention of woman abuse (Transken, 2000; Warshaw, 1994; Varcoe, 1997;
Ingram, 1994 ). By implementing formal screening policies which ensure that all women
(regardless of background) are asked about abuse, health care workers can use their front-line
status in the community to prevent women from further victimization, serious injury or even
death. I have demonstrated that universal screening entails properly identifying and treating the
consequences of abuse, as well as validating women's experiences, documenting injuries and
referring women to sources of support. The main goal of this case study, however, was to show
how universal screening could also be a forum for fostering women's empowerment. I have
argued that one of the most important qualities of empowerment practice is that the focus is
placed on the process of screening, as opposed to the goal of disclosure. This means resisting
the need to fix the problem and realizing that women know what they need better than anyone
else in their circumstances (Roux & Rittmayer, 1999; Ingram, 1994). I have argued that because
women residing in northern communities usually have fewer avenues of support, screening is

84

especially critical. The current climate of cutbacks to funding for BC social services and other
programs (legal aid, victims ' services, women' s centres, social assistance benefits, etc.) will
surely have a negative impact on the most vulnerable members of society, particularly those
trying to escape violence. This means that now, more than ever, victims of violence need to be
able to count on the support and advocacy of all committed members of the social service and
·health care sector, particularly in underserviced areas. On a final note, in keeping with the tenets
of feminist scholarship, it is hoped that this case study will give a voice to a subject that is
seldom heard, and that this paper will be understood to be not simply "about women" but "for
women" (Reinharz, 1992). With this said, it is hoped that health care workers in the north will
be motivated to examine current practices and policies regarding woman abuse and consider
implementing a universal screening protocol that could have a positive impact on women,
families and society at large.

85

ENDNOTES
1

Consistent with a feminist perspective on woman abuse, this paper utilizes a "violence against
women in relationships" perspective. The reason for this is that terms such as "family violence,"
"domestic violence," or "wife abuse" tend to obscure the severity and gender nature of the
violence and limit the scope of the problem (Kurz, 1997). A violence against women
perspective is one that acknowledges that it is most often women, not men, who are victims of
violence. Although some men are victims of violence in relationships, numerous studies show
that the overwhelming majority of victims of partner violence are women and that women
sustain more serious injuries in violent disputes (Koss, 1994; Johnson, 1996; Statistics Canada,
1999; U.S. Dept. of Justice, 2000). In addition, when women use physical force toward their
male partner, it is often in self-defense and rarely part of a continuing pattern of control and
coercion (Warshaw as cited in Cole, 2000).
2

Due to limited space I will not be able to offer a comprehensive discussion about the subject of
domestic violence in Aboriginal communities. While every person's experience with abuse is
unique, it must be pointed out that there are distinct social, historical and economic factors that
contribute to the high incidence of domestic violence found in many Canadian Aboriginal
communities. For more information about this subject, see Frank, 1992; LaRocque, 1994;
Green, 1996; Maracle, 1996; and McTimoney, 1993.
3

This paper is written with the understanding that every woman's experience with violence is
unique, regardless of geographic location or background. The aim of this discussion is not to
generalize, but to show how the northern landscape can play a significant role in shaping
women's victimization and help-seeking abilities.
4

Due to the limited scope of this paper, I will not be exploring the issue of screening for child
abuse in the health care setting. However, it is worth noting that the American Academy of
Pediatrics, American Medical Association (AMA), American Academy of Family Physicians
and the Bright Futures guidelines all recommend that physicians be on the alert for signs and
symptoms of child physical abuse and child sexual abuse in routine examinations. The AMA's
Guidelines for Adolescent Preventive Services recommend that teens should be asked annually
about a history of emotional, physical and sexual abuse. The use of screening devices to identify
families at risk for child maltreatment is not recommended by the Canadian Task Force on the
Periodic Health Examination. Legislation in the US and Canada requires health care
professionals to report suspected cases of child abuse (U.S. Task Force on Preventive Health,
1996).
5

A useful resource recommended for health care practitioners to become more aware of the
dynamics of woman abuse is the "power and control wheel," a model developed by the
Domestic Abuse Intervention Project in Duluth, Minnesota (Yllo, 1993). This model is based on
a feminist perspective of woman abuse and is often used in transition houses, support groups
and educational settings. It clearly demonstrates the interconnections between violence and
other forms of coercive control. For example, this framework shows how a wheel connects
physical and sexual violence to the hub of power and control, connecting to spokes which
represent the various forms of control: minimization and denial, intimidation, isolation,

86

emotional abuse, economic abuse, use of children, threats and asserting male privilege (Yllo,
1993).
6

For a more comprehensive discussion on cultural studies see Agger, 1992; Grossberg, Neslon,
& Treichler, 1992; Storey, 1996; and Sardar & Van Loon, 1999.
7

Johnson (2000) and Morrow (2000) offer a comprehensive list of health professional resources
and initiatives pertaining to violence against women.
8

The goal of this paper is to encourage health care workers and other helping professionals to
recognize the benefits of screening for abuse, not to advocate for one particular tool over
another. However, in addition to the Vancouver General Hospital screening guidelines, there are
numerous screening protocols available for use in a wide range of health care settings. For more
information about the efficacy of screening tools see Feldhaus et al., 1997.

87

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