Responding to intimate partner violence and sexual violence against women WHO clinical and policy guidelines Responding to intimate partner violence and sexual violence against women WHO clinical and policy guidelines WHO Library Cataloguing-in-Publication Data: Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. 1.Spouse abuse -prevention and control. 2.Violence -prevention and control. 3.Battered women. 4.Sex offenses -prevention and control. 5.Women's health services. 6.Review. 7.Health policy. 8.Guideline. I.World Health Organization.#
Women who have been subjected to violence often seek health care, including for their injuries, even if they do not disclose the associated abuse or violence. A health-care provider is likely to be the first professional contact for survivors of intimate partner violence or sexual assault. Statistics show that abused women use health-care services more than non-abused women do. They also identify health-care providers as the professionals they would most trust with disclosure of abuse.
These guidelines aim to provide evidencebased guidance to health-care providers on the appropriate responses to intimate partner violence and sexual violence against women, including clinical interventions and emotional support. They also seek to raise awareness, among health-care providers and policymakers, of violence against women, to better understand the need for an appropriate healthsector response to violence against women.
The guidelines are based on systematic reviews of the evidence on identification and clinical care for intimate partner violence, clinical care for sexual assault, and training relating to intimate partner violence and sexual assault against women, as well as policy and programmatic approaches to delivering services and mandatory reporting of intimate partner violence. They provide standards that can act as the basis for national guidelines, and for integrating these issues into health-care provider education, as well as helping healthcare providers to be better informed about the care of women experiencing sexual assault and intimate partner violence.
Although men are also victims of partner violence and sexual assault, these guidelines focus on women, because they experience more sexual violence, more severe physical violence, and more coercive control from male partners. However, much of the advice given will be relevant in respect of violence against women by family members other than intimate partners and may be relevant for partner abuse of men. Some of the advice will also be relevant to sexual assault of men.

# Target audience
The guidelines are aimed at health-care providers because they are in a unique position to address the health and psychosocial needs of women who have experienced violence. Health professionals can provide assistance by facilitating disclosure; offering support and referral; providing the appropriate medical services and follow-up care; or gathering forensic evidence, particularly in cases of sexual violence.
The guidelines offer health-care providers evidence-based guidance on appropriate care, including clinical interventions and emotional support, for women suffering from intimate partner violence and sexual violence. They also seek to make health-care providers and policymakers more aware of violence against women, to encourage an evidence-informed healthsector response, and improve capacity-building of health-care providers and other members of multidisciplinary teams. They should also prove useful to those responsible for developing training curricula in medicine, nursing and public health.
The guidelines also include a servicedelivery and programme-guidance component aimed at those responsible for developing, funding and implementing programmes to address violence against women. The level of resources available, including other support services, will need to be taken into account when implementing the recommendations. The World Health Organization (WHO) will partner with ministries of health, nongovernmental organizations (NGOs) and sister United Nations agencies to disseminate these guidelines, and support their adaptation and implementation in Member States.

# Guideline development methods
The process used in the development of these guidelines, which is outlined in the WHO handbook for guideline development, 1 involved: (i) identification of questions related to clinical practice and health policy; (ii) retrieval of up-to-date evidence; (iii) assessment and synthesis of the evidence; (iv) formulation of recommendations with inputs from a wide range of stakeholders; and (v) formulation of plans for dissemination, implementation and updating.
The scientific evidence for the recommendations was synthesized using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology for the clinical interventions. For each preselected critical question, evidence profiles were prepared from existing or commissioned systematic reviews. For the questions on policy and health-care delivery, the descriptive evidence was summarized, with the strengths and weaknesses of different approaches identified.
The Guideline Development Group (GDG) included academics, clinicians/service providers and policy-makers, working on women's health and violence against women in low-and middle-income countries, as well as women's health and rights advocates, thereby ensuring the representation of a wide range of user opinion. The recommendations were developed by WHO in association with the GDG, during a meeting at the WHO office in Geneva between 12 and 14 September 2011. The recommendations take into account the evidence, as well as considerations of the balance between benefits and harms, women's preferences and their human rights, and the cost implications in different countries and communities worldwide. Where there was a need for guidance, but no relevant research evidence, recommendations were agreed using the expertise of the GDG.
For clinical interventions, the quality of the supporting evidence was graded as very low, low, moderate, or high, using GRADE methodology. For some recommendations, existing guidelines were relied on in part, and the quality of the evidence in those guidelines was assessed. Where existing guidelines provided only indirect evidence, in other words evidence not directly applicable to these populations and settings, the quality of the evidence was labelled as such. Recommendations on health-care policy and provision, and on mandatory reporting, were considered to be best practices or to address human rights. For those recommendations, we also systematically searched for relevant literature and summarized it qualitatively, but did not use GRADE to assess the evidence and best practices. When no evidence was identified for either a clinical or a health policy recommendation, this was indicated in the summary of the evidence.
Recommendations were considered as strong or conditional, on the basis of the generalizability of benefit across different settings, and the needs and preferences of women to access services, as well as taking into consideration the level of human and other resources that would be required. In order to ensure each recommendation could be understood and used in accordance with its intended meaning, the GDG offered further clarifications, which are noted below the recommendations as remarks.
Input from peer reviewers and a range of stakeholders, including colleagues working directly with women survivors of violence, was also sought and helped to further clarify the wording of the recommendations. Important knowledge gaps that need to be addressed through primary research were identified, which allowed a list of critical research questions to be developed.

# Summary of recommendations
Quality of evidence Recommendation

# Women-centred care
1 Women who disclose any form of violence by an intimate partner (or other family member) or sexual assault by any perpetrator should be offered immediate support. a Health-care providers should, as a minimum, offer firstline support when women disclose violence. First-line support includes:
- being non-judgemental and supportive and validating what the woman is saying - providing practical care and support that responds to her concerns, but does not intrude - asking about her history of violence, listening carefully, but not pressuring her to talk (care should be taken when discussing sensitive topics when interpreters are involved) - helping her access information about resources, including legal and other services that she might think helpful - assisting her to increase safety for herself and her children, where needed - providing or mobilizing social support.

# Providers should ensure:
- that the consultation is conducted in private - confidentiality, while informing women of the limits of confidentiality (e.g. when there is mandatory reporting)
If health-care providers are unable to provide firstline support, they should ensure that someone else (within their health-care setting or another that is easily accessible) is immediately available to do so. - start the regimen as soon as possible and before 72 hours - provide HIV testing and counselling at the initial consultation - ensure patient follow-up at regular intervals - two-drug regimens (using a fixed dose combination) are generally preferred over three-drug regimens, prioritizing drugs with fewer side-effects - the choice of drug and regimens should follow national guidance.

# Indirect evidence c
Strong 18 Adherence counselling should be an important element in PEP provision.

# Very low Strong

# Post-exposure prophylaxis for sexually transmitted infections
19 Women survivors of sexual assault should be offered prophylaxis for:
- chlamydia - gonorrhoea - trichomonas - syphilis, depending on the prevalence.
The choice of drug and regimens should follow national guidance.

# Low-very low, based on indirect evidence
Strong 20 Hepatitis B vaccination without hepatitis B immune globulin should be offered as per national guidelines.
- Take blood for hepatitis B status prior to administering the first vaccine dose. - If immune, no further course of vaccination is required.  Geneva, World Health Organization, 2008 b In two cohort studies of HIV PEP, seroconversion rates ranged from 0% to 3.7%. c Joint ILO/WHO guidelines on post-exposure prophylaxis to prevent HIV infection. Geneva, World Health Organization, 2008. d This recommendation is adapted from Psychological first aid. Geneva, World Health Organization, 2011, aimed at individuals in community crisis situations (whqlibdoc.who.int/publications/2011/9789241548205_eng.pdf).
Recommendations Quality of evidence Recommendation 3.2 PsyCHOlOgICAl/mentAl HeAltH InteRventIOns AfteR 5 dAys

# Interventions up to 3 months post-trauma
Continue to offer support and care as described in recommendation 10.

# Indirect evidence a
Strong 25 Unless the person is depressed, has alcohol or drug use problems, psychotic symptoms, is suicidal or selfharming, or has difficulties functioning in day-to-day tasks, apply "watchful waiting" for 1-3 months after the event.
Watchful waiting involves explaining to the woman that she is likely to improve over time, and offering the option to come back for further support by making regular follow-up appointments. - enables them to provide first-line support (see recommendations 1 and 10) - teaches them appropriate skills, including:
-when and how to enquire -the best way to respond to women (refer to sections 2 Identification and care for survivors of intimate partner violence and 3, Clinical care for survivors of sexual assault) -how to conduct forensic evidence collection where appropriate a - addresses:
-basic knowledge about violence, including laws that are relevant to victims of intimate partner violence and sexual violence -knowledge of existing services that may offer support to survivors of intimate partner violence and sexual violence (this could be in the form of a directory of community services) -inappropriate attitudes among health-care providers (e.g. blaming women for the violence, expecting them to leave, etc.), as well as their own experiences of partner and sexual violence. 37 Mandatory reporting of intimate partner violence to the police by the health-care provider is not recommended. However, health-care providers should offer to report the incident to the appropriate authorities (including the police) if the woman wants this and is aware of her rights.

# Very low Strong
38 Child maltreatment and life-threatening incidents must be reported to the relevant authorities by the health-care provider, where there is a legal requirement to do so.

# Very low Strong
a Existing evidence was reviewed but GRADE was not used, owing to largely descriptive and qualitative data.
Violence against women 1 is a major public health and human rights concern, with intimate partner violence and sexual violence among the most pervasive forms of violence against women. Research, initially from North America and Europe, but increasingly from other regions, has demonstrated the high prevalence of violence against women globally and its adverse physical and mental health outcomes, in both the short and long term (Campbell, 2004;Garcia-Moreno et al., 2005;Ellsberg et al., 2008;Bott et al., 2012). Health-care providers frequently, and often unknowingly, come into contact with women affected by violence, since abused women make extensive use of health-care resources (Ansara and Hindin, 2010;Black, 2011). Health-care providers are in a unique position to create a safe and confidential environment for facilitating disclosure of violence, while offering appropriate support and referral to other resources and services.
As detailed in the report of the WHO multicountry study on women's health and domestic violence against women (Garcia-Moreno et al., 2005), the global statistics show: y between 13% and 61% of women 15-49 years old report that an intimate partner has physically abused them at least once in their lifetime y between 6% and 59% of women report forced sexual intercourse, or an attempt at it, by an intimate partner in their lifetime y from 1% to 28% of women report they were physically abused during pregnancy, by an intimate partner.
However, although violence against women has been accepted as a critical public health and clinical care issue, it is still not included in the health-care policies of many countries. The critical role that the health system and health-care providers can play in terms of identification, assessment, treatment, crisis intervention, documentation, referral, and follow-up, is poorly understood or accepted within the national health programmes and policies of various countries. Health-care professionals tend to regard violence against women as a criminal justice issue, and view partner violence in particular as a domestic matter. They are also ill-equipped to deal with the issues, since medical and nursing education in many countries does not address this problem. In order for health-care providers to assume their roles in mitigating the effects of violence and fulfil their responsibility, it is necessary to sensitize them towards the issue and provide them with the information and tools necessary to respond sensitively and effectively to survivors. These guidelines are a first step in this direction. Studies of the relationships between intimate partner violence, health status and use of health care by women have shown that women who have experienced violence are more likely than non-abused women to seek health care (Ansara and Hindin, 2010;Black, 2011), even if they do not disclose the violence. A health-care provider is often the first contact for survivors of intimate partner violence and sexual assault, and women living with partner violence identify health-care providers as the professionals they would most trust with disclosure of abuse (Feder et al., 2006).
Irrespective of the circumstances, healthcare providers who come into contact with women facing violence need to be able to recognize signs of it, and respond appropriately and safely. Individuals who have been exposed to violence require comprehensive, gendersensitive health-care services that address the physical and mental health consequences of their experience and aid their recovery from what is a traumatic event. They may also require crisis intervention services (see Glossary) in order to prevent further harm, although more often than not, a supportive response is needed. In addition to providing immediate health care, the health sector is potentially a crucial gateway (via referral pathways) to specific services for violence against women (where they exist), or to other services that the woman may require at a later date, such as social welfare and legal aid. Documentation of injuries, health complaints and other problems resulting from violence can be used by the abused woman in a court of law as evidence, should she choose to take legal action. In addition to addressing the health consequences of violence, health-care providers, are also well placed to collect and document the evidence necessary for corroborating the circumstances of the reported abuse, and to help identify the perpetrator. Such evidence is often crucial to the prosecution in cases of violence, although these guidelines will not cover a full forensic examination. (For further information on this, see World Health Organization  Guidelines for medico-legal care of victims of sexual violence  Member States themselves have requested clearer guidance on what constitutes an appropriate health-service response to violence against women. Thus, the guidelines focus on intimate partner violence and sexual violence against women and present healthcare providers with evidence-based guidance on how best to identify and respond to women who report experiencing violence. The guidelines also, for the first time, provide guidance on in-service training on intimate partner and sexual violence against women, for health-care providers and other members of multidisciplinary teams. While these guidelines focus on the health-sector response, we recognize that an appropriate response to violence against women requires multisectoral collaboration.
The guidelines also provide guidance for policy-makers and others in charge of planning, funding and implementing health services and professional training within health ministries, as well as policy-makers with responsibility for developing guidelines for curricula in the areas of medicine, nursing and public health. This is the first time WHO has issued guidance in this area. Policy-makers are in a position to ensure not only that the different services for women who experience violence are provided in a coordinated fashion and are adequately funded, but also that the issue is given the appropriate priority within relevant training programmes. The guidelines can also be used as a blueprint for the design of suitable healthcare delivery systems for national, regional and local authorities, and to guide the content of educational curricula on service provision for women who experience violence.
These guidelines have been developed with particular regard for health-care providers working in settings where there may be severe constraints on the capacity to provide comprehensive health services. These guidelines will need to be adapted to specific local and/ or national circumstances, taking into account the availability of resources, as well as national policies and procedures.
The level of resources available, including other support services, will also need to be taken into account in the implementation of the recommendations. WHO will partner with ministries of health, nongovernmental organizations (NGOs) and sister United Nations agencies to disseminate these guidelines, and support their adaptation and implementation in the countries involved.

# Scope of the guidelines
The guidelines focus on violence (physical, sexual and emotional) by an intimate -usually male-partner, and sexual assault of women by men, because they are the most common forms of violence against women that occur in all settings. Our recommendations do not cover female genital mutilation, trafficking or other forms of violence against women.
Similarly, although men are also victims of partner violence and sexual assault, these guidelines focus exclusively on women because they experience more sexual violence, more severe physical violence, and more coercive control from male partners. In addition, we have very limited evidence on interventions for men (Tjaden and Thoennes, 2000;Walby and Allen, 2004;AuCoin, 2005).
While the focus is on male partner violence against women, much of the advice will be relevant in respect of violence against women by family members other than intimate partners and may be relevant for partner abuse of men. Some of the advice will also be relevant to sexual assault of men.
The recommendations on women-centred care (section 1, pp. 16 and 17) apply to both intimate partner violence and sexual assault, and the recommendations for survivors of sexual assault (section 3, pp. 25-34) are relevant for survivors/victims of sexual assault, irrespective of the perpetrator.

# Human rights underpinning of the guidelines
Intimate partner violence and sexual violence have been recognized as violations of women's human rights, including their rights to freedom from discrimination, 1 to life, to integrity and security of the person, 2 and to the highest attainable standard of health. 3 Marital rape, in particular, has been acknowledged to be a form of violence against women 4 and deemed contrary to respect for human dignity. 5 Under human rights treaties that governments have signed, there is a responsibility to prevent, investigate and punish all forms of violence against women. 1 For instance, states that are party to the International Covenant on Civil and Political Rights are required to report on laws that address violence against women and specific prevention and response measures. The United Nations Human Rights Committee specifically requires information on "measures of protection, including legal remedies, for women whose rights under article 7  have been violated". 6 Meeting this responsibility to prevent, investigate and punish all forms of violence against women requires specific and targeted government action through the health sector, as well as other sectors such as justice and education. International and regional human rights bodies have provided guidance on the contribution that health-care professionals can -and shouldmake towards ensuring women's freedom from gender-based violence, as well as providing an adequate response when such violence has occurred.
For instance, according to the United Nations Committee on the Elimination of all Forms of Discrimination against Women (CEDAW), States Parties to the CEDAW Convention should ensure the following (among other measures): y women-centred care is offered in the form of acceptable health services -these are services that "are delivered in a way that ensures that a woman gives her fully informed consent, respects her dignity, guarantees her confidentiality and is sensitive to her needs and perspectives" 7 y policies, including health-care protocols and hospital procedures, that address violence against women and sexual abuse of girls, and allow the provision of appropriate health services. 8 Health-care policy and provision should place "gender perspective at the centre of all policies and programmes affecting women's health and should involve women in the planning, implementation and monitoring of such policies and programmes and in the provision of health services to women"; all health-care services should be "consistent with the human rights of women, including the rights to autonomy, privacy, confidentiality, informed consent and choice"  (Schunemann et al., 2009), as defined in the WHO methods handbook (2010b), was used. The studies were double extracted and appraised. The different appraisals were then compared and discussed between the two reviewers and, where there was a difference, this was resolved by a third reviewer. Reviews on mental health interventions in populations experiencing intimate partner or sexual violence were complemented by the more general evidence in the WHO mental health guidelines (WHO, 2010c) (recommendations 5, 27 and 28). Where clinical recommendations were based on indirect evidence (in other words evidence that was not directly from the 13 Methods population of women suffering intimate partner violence or sexual assault), the assessment of the quality of the evidence was labelled accordingly. Indirect evidence was largely based on existing guidelines on emergency contraception, STIs prophylaxis and related mental health and other issues. Where no evidence was available, recommendations were made because they were considered to be best practices or they addressed human rights and equity issues, and the lack of relevant evidence was noted.
For questions related to health-care policy and provision and to mandatory reporting, the literature was systematically reviewed, the available data compiled in evidence tables, and these data qualitatively summarized. GRADE methodology was not used, however, to assess the quality of the body of evidence for these types of questions, because the individual studies were too heterogenous and most had serious methodological limitations. In addition, many of the questions and recommendations were based on best practices, human rights conventions, and issues of equity, which do not lend themselves to GRADE methodology. The GDG therefore reviewed the qualitative summary of the available data and formulated recommendations based on those data, as well as on best practices, and on human rights principles and conventions. The assessment of the quality of evidence for these recommendations was labelled as very low.

# Recruitment of the Guideline Development Group
The GDG was made up of academics, clinicians, government officials and advisers on healthcare policy, as well as people who worked directly with women experiencing violence and women's health and rights advocates from lowand middle-income countries. Consideration was given to geographic diversity and gender balance, although the latter was difficult as this field is dominated by women.
Potential members of the GDG were selected on the basis of their contribution to the area, as well as the need for regional and area of expertise diversity. The 25 attendees at the 2009 Expert meeting on health-sector responses to violence against women (WHO, 2010a) represented a wide variety of stakeholders within the field. As a respected researcher in the field, the chairman was selected for his extensive experience of guideline development methodology and of chairing guideline development groups. The potential GDG members were identified, in part from among the attendees of the 2009 meeting, who were asked to send in a personal statement and complete the WHO declaration of interest form. The personal statements were reviewed by the Steering Group.

# Declaration of interest by Guideline Development Group members and peer reviewers
All GDG members and participants of the meeting completed a declaration of interests form prior to the meeting. These forms were reviewed by the responsible officer at WHO, the senior coordinator in the WHO Department of Reproductive Health and Research (RHR), and the project manager, before finalization of the group composition and invitation to attend the GDG meeting. Annex II contains a summary of the relevant declarations of interest. The peer reviewers, who were sent the guidelines for review, also submitted a declaration of interest form prior to reviewing the guidelines, and these were also similarly reviewed. Procedures for management of conflicts of interest were based on WHO Guidelines for declaration of interest (WHO experts). This is not a field with significant financial interests, but it does contain publicly stated opinions and research that are of interest. Because the GDG membership included many of the key researchers in the field, before each topic was discussed, members declared which studies they had been involved in, and in these cases they did not actively participate in the discussion but only responded in order to clarify any questions posed by other GDG members. Because of a stated public position, the chairman stood down during the discussion on 'screening' for intimate partner violence, allowing the session to be chaired by the WHO officer responsible for the guidelines.

# Decision-making during the Guideline Development Group meeting
The GDG met at the WHO in Geneva for a three-day meeting between 12 and 14 September 2011. The review of evidence was sent out in advance so it could be summarized in a presentation during the meeting. The GDG members began by discussing the evidence, clarifying points of fact, and interpreting the findings. In terms of developing recommendations, the GDG recognized that there exists a very wide variation from region to region in the prevalence of violence against women, the laws to protect women, and the resources available to help them. It was therefore particularly necessary for the GDG to consider the relevance of the evidence in this context, using the following considerations: y the balance of benefits versus the harms of an intervention; y values and preferences of women, sensitivity to women's needs and concerns, and human rights standards such as the right to information, respect and dignity; and y costs and resource use and other relevant feasibility issues of providers in low-and middle-income settings.
The GDG set the evidence into context using the considerations above. Where there was a need for guidance, but no relevant research evidence was available, recommendations were developed using the expertise of the GDG and the considerations above.
Taking into account the above considerations, if it was agreed that the recommendation would be of near universal benefit, it would be rated as a strong recommendation. If however, there were caveats on its benefit in different contexts, it was rated as conditional. The recommendations on health-care policy and provision (section 5) were based on the systematic reviews that primarily found descriptive observational studies. The recommendations on training of health care providers (section 4) and on healthcare policy and provision (section 5) recognized the dual objectives of equitable access and good quality care, and the importance of training providers to be competent in responding to women survivors of violence, so they can access services and do so in a way that protects and promotes their health and rights. The feasibility of implementing the recommendations in country settings with limited human and other resources was also taken into account.
The wording and strength of each recommendation was determined, in most cases, through consensus. Unanimous agreement was reached for all but two recommendations. (These were recommendation 2, regarding 'universal screening', and recommendation 7, regarding advocacy/support/empowerment for intimate partner violence.) Where the agreement was not unanimous, the outcome was decided upon by a vote. The reviewer of the topic, and WHO staff, were exempt from voting, but regional WHO staff who had been invited as advisers did vote. In these two cases, the minority opinion is written up in the discussion or remarks in the relevant section.

# Document preparation and peer review
In addition to the GDG members, suitable peer reviewers were identified to allow input from a wider range of stakeholders.
Both GDG members and peer reviewers were invited to: y rate the outcomes of the PICOT questions in advance of the evidence reviews y comment on the reviews and draft recommendations of the clinical interventions for sexual assault and intimate partner violence prior, to the meeting methods y comment on the other reviews, following the meeting but prior to revision y comment on the final guidelines document after the meeting.
All comments were collated by the Steering Group, with each comment reviewed and responses added to the comments in a table (available on request). Relevant revisions were then made to the documents, before the revised version was sent back to the members of the GDG for a final review. A total of 26 people commented on the PICOT questions and rated the outcomes (a table of ratings is available on request). The systematic reviews and GRADE or other tables were prepared and presented to the GDG to inform the recommendations. The following section contains the summaries of the evidence and the evidence-informed recommendations for each of the broad areas covered by the guidelines. Many people, including WHO staff, peer reviewers, stakeholders and GDG members, participated in the consultation on the review of evidence and in the preparation of the final guidelines.

# Women-centred care
Women who experience intimate partner violence or sexual violence can have very different needs, depending on their circumstances and the severity of the violence and its consequences. Furthermore, women in similar circumstances may need different types of support over time. There are, however, a minimum set of actions and principles that should guide the health-care response to women suffering from violence (physical, sexual or emotional), whether by an intimate partner, relative, acquaintance or stranger, regardless of the circumstances. This minimum first-line supportive response is outlined in the recommendation below.

# from evidence to recommendation
This recommendation is based on the experience of those working with survivors of intimate partner violence and sexual violence, and builds on the recommendations of the WHO publication, Psychological first aid (WHO, 2011), with the specific elements adapted by the GDG to deal with violence against women. Psychological first aid is aimed at individuals in community crisis situations; there is only indirect evidence for "psychological first aid" (see y providing practical care and support that responds to her concerns, but does not intrude y asking about her history of violence, listening carefully, but not pressuring her to talk (care should be taken when discussing sensitive topics when interpreters are involved) y helping her access information about resources, including legal and other services that she might think helpful y assisting her to increase safety for herself and her children, where needed y providing or mobilizing social support.
Providers should ensure: y that the consultation is conducted in private y confidentiality, while informing women of the limits of confidentiality (e.g. when there is mandatory reporting)
If health-care providers are unable to provide first-line support, they should ensure that someone else (within their health-care setting or another that is easily accessible) is immediately available to do so.

# Quality of evidence: Indirect evidence was identified Strength of recommendation: Strong
(a) Any intervention must be guided by the principal to "do no harm", ensuring the balance between benefits and harms, and prioritizing the safety of women and their children as the uppermost concern.
(b) The privacy and confidentiality of the consultation, including discussing relevant documentation in the medical record and the limits of confidentiality with women, should be a priority. Therefore, good communication skills are essential.
(c) Health-care providers should discuss options and support women in their decision-making. The relationship should be supportive and collaborative, while respecting women's autonomy. Health-care providers should work with the women, presenting options and possibilities, as well as providing information, with the aim to develop an effective plan and set realistic goals, but the woman should always be the one to make the decisions.
(d) In some settings, such as emergency care departments, as much as possible should be done during first contact, in case the woman does not return. Follow-up support, care, and the negotiation of safe and accessible means for follow-up consultation should be offered.
(e) Health-care providers need to have an understanding of the gender-based nature of violence against women, and of the human rights dimension of the problem.
(f) Women who have physical or mental disabilities are at an increased risk of intimate partner and sexual violence. Health-care providers should pay particular attention to their multiple needs. Women who are pregnant may also have special requirements (see recommendation 8).

# Identification and care for survivors of intimate partner violence
This section covers identification of survivors of intimate partner violence and the clinical interventions that address it.

# Identification of intimate partner violence
There has been much debate about the safe and effective identification in healthcare settings of women experiencing intimate partner violence. Some individuals, particularly in the United States of America (USA), advocate asking all women consulting health-care providers about partner violence ("universal screening" or "routine enquiry"), while others argue the case for a more selective approach on the basis of clinical and diagnostic considerations ("clinical enquiry" or "casefinding") (see Glossary). In general, studies have shown that screening for intimate partner violence (i.e. systematically asking all women about violence) increases the identification of women with intimate partner violence, but have not shown a reduction in intimate partner violence, nor any notable benefit for women's health.
The evidence was assessed to identify "the effects of interventions aimed at identifying women survivors of intimate partner violence delivered at the health system level".

# evidence summary
An unpublished WHO review on screening and clinical interventions for intimate partner violence (available on request), an update of a previous systematic review (Feder et al., 2009), concluded there was insufficient evidence to support the idea that screening leads to a reduction in intimate partner violence or an improvement in quality of life or health outcomes, concluding that the connection between the two was complex. The current review therefore identified "screening" programmes that also offered post-screening action, in the hope that this would be more likely to go beyond increased detection rates and health-care provider acceptance, thus leading to improved outcomes for the women. In the screening programmes considered in this review, the most common type of "action" described was a prompt in the medical record of the screening test result provided to the health-care provider before the visit, or automatic referrals to social workers or professional advocates.
Of the four additional studies (Rhodes et al., 2006;Ahmad et al., 2009;MacMillan et al., 2009;Koziol-McLain et al., 2010) not reviewed in Feder et al. (2009), most were implemented in an emergency department setting (n = 4), two were conducted in family practice ambulatory settings (Ahmad et al., 2009;MacMillan et al., 2009), and two were conducted in obstetrics/ gynaecology or antenatal clinic settings, or a family practice (MacMillan et al., 2009;Humphreys et al., 2011). In total, there were 1919 women in these studies; two studies were in Canada, one in New Zealand and one in the USA. MacMillan et al. (2009) did not report findings by study site.
No studies were found to have demonstrated an important or statistically significant reduction in recurrence of intimate partner violence. The MacMillan et al. ( 2009) and the Koziol-McLean et al. (2010) randomized-efficacy trials had similar findings of a small effect size (odds ratio of 0.82 and 0.86, respectively, not statistically significant) in family practice, obstetrics and gynaecology clinics and emergency departments in Ontario Canada, and the emergency department of an urban hospital in New Zealand respectively.
Only one study, a randomized controlled trial, was found to have assessed multiple health outcomes -quality of life, and symptoms of depression and post-traumatic stress disorder (PTSD) (MacMillan et al., 2009). At 18 months' follow-up, there were no important differences in these health outcomes. Hence, similar to the findings of earlier reviews, there remains insufficient evidence that screening plus action leads to a reduction in recurrence of intimate partner violence, or an improvement in quality of life or health outcomes.
A more recent randomized clinical trial of intimate partner violence screening in the USA (Klevens et al., 2012) that measured recurrence of intimate partner violence and improvements in quality of life and other health outcomes, strengthened the evidence for recommendation 2, which recommends against the screening of all women in health-care settings for intimate partner violence. Overall, the quality of the available evidence for screening studies was graded low to moderate, and showed that screening women for intimate partner violence in health-care settings did not fulfil the public health criteria for implementation of a screening programme. There are no studies measuring outcomes for women comparing identification through screening versus case-finding or clinical enquiry. While there is one trial (MacMillan et al., 2009) showing no harm caused by screening, another study conducted in antenatal settings detected potential harm (Bachus et al., 2010).

# from evidence to recommendations
One of the public health criteria for screening is the availability of an effective response.
The review of screening studies summarized above considered quality of life, recurrence of intimate partner violence, and referral rates as outcomes. In addition to the evidence, issues considered by the GDG included the opportunity cost and usefulness of screening in settings with very high prevalence and limited referral options and sustainability, and potential risks and concerns for women's safety. Based on the experience of some members of the GDG, these considerations included:
y The high burden of universal screening where there is high prevalence, particularly in settings with limited referral options and overstretched resources/providers, which translates into opportunity costs of overstretched health-care providers and a limited capacity for responding to women who may be identified through screening. In these settings, focusing on selective enquiry based on clinical considerations is more likely to benefit women. y Women may find repeated enquiry difficult, particularly if no action is taken. This may potentially reduce their uptake of health services.
y While screening increased detection, it also tends to increase resistance from clinicians, and rates of screening tend to decrease rapidly. It can easily become a tick-box exercise carried out without due consideration, or undertaken in an ineffectual way. y Training providers to ask all women about violence when there are limited options to offer them has an important opportunity cost. It is preferable to focus on enhancing providers' ability to respond adequately to those who do disclose violence, show signs and symptoms associated with violence, or are suffering from severe forms of abuse.
A minority of GDG members thought that the benefits of universal screening outweighed the disadvantages. Their reasons were:
y It increases detection, without which intervention cannot take place (even though options for this are limited). y Screening programmes do not seem to harm individuals, and most women do not object to being asked. y Health-care providers are not necessarily familiar with the signs and symptoms of intimate partner violence and may only ask women who they think may be at risk, increasing the potential for stereotyping. y There is also a risk that if the enquiry is selective, it could mean that health-care providers will avoid asking if they feel uncomfortable (although this happens even when universal screening is the recommended approach). The evidence for addressing the effectiveness of clinical interventions came from these new studies, as well as 14 prior studies that met the inclusion criteria from three previous systematic reviews (Sadowski and Casteel, 2010;Ramsay et al., 2006;andunpublished WHO 2009 update of Ramsay et al., 2006 The 20 studies of advocacy/empowerment and psychological interventions had both methodological strengths and limitations. The quality of evidence ranged from low (13) to moderate (7). All were randomized controlled trials using standardized assessment instruments and outcomes rated as "important" or "critically important". The limitations included the lack of blinding of the randomization process or outcome assessment, high attrition rate of the sample, and, frequently, very small sample size, which rendered the study underpowered. The heterogeneity of the studies precluded data pooling of underpowered studies and metaanalysis.
Since the last systematic review, the field has been active and has expanded the body of evidence considerably. Also, the newer studies have been conducted in health-care settings, demonstrating the feasibility of studying intimate partner violence in this setting, presumably gaining increased support from the health sector in the process.

# Psychological/mental health interventions evidence summary
There were five studies that evaluated this type of intervention (Kubany et al., 2004;Gilbert et al., 2006;Zlotnick et al., 2011). In a few of these, the intervention was tailored for women who had experienced intimate partner violence, and contained elements of advocacy or empowerment. As it was not possible to tease the components apart, their findings contribute to the body of evidence in both the advocacy/empowerment and psychological intervention categories. These studies show that some form of individual cognitive behavioural therapy (CBT) interventions for women who have experienced intimate partner violence may reduce PTSD and depression (during pregnancy), compared with no intervention, with one study reporting better birth outcomes. However, there is no evidence to suggest these interventions have a beneficial effect on quality of life as measured in the studies. From a previous systematic review, nine controlled studies of group psychological interventions were identified, including four randomized controlled trials (Wingood, Gilbert, Laverde, Melendez), one case control (Arinero), and four parallel group studies (Cox, Limandri, Rinfert-Raynor, Kim). They included studies based in Colombia and Korea and evaluated highly heterogeneous, psychologically based interventions and outcomes. Although the majority reported some positive outcomes, the quality of the overall study design and conduct was poor.

# from evidence to recommendations
For individual psychological interventions, CBT interventions are recommended for women who are no longer experiencing violence but are suffering from PTSD. The evidence for this specific population is low quality, but comes supported by a much larger body of evidence for CBT that is of moderate quality. There is insufficient evidence to recommend CBT for women who are still experiencing intimate partner violence.
There was insufficient evidence to recommend a group psychological intervention for women who have experienced intimate partner violence.
However, the GDG wished to remind health-care providers that women with diagnosed mental health disorders who suffered intimate partner violence should receive mental health care as advised in the WHO Mental Health Gap Action Programme (mhGAP) guidelines (WHO, 2010), provided by professionals with an understanding of the impact and management of violence against women (Howard et al., 2010).
There is a substantial existing body of literature on the treatment of a range of mental disorders, including depression and PTSD. WHO already has guidelines on treatment of depression, psychosis and alcohol use disorders, among other conditions (WHO, 2010;Dua et al., 2011). WHO is currently working on mhGAP guidelines and clinical protocols for acute stress, bereavement and PTSD. The WHO mhGAP Guidelines Development Group has thus far approved the recommendations shown in Box 2 that are potentially relevant to victims/survivors of intimate partner violence.

# Advocacy/empowerment interventions evidence summary
Fifteen studies of interventions defined as advocacy or empowerment were identified (McFarlane et al., 2000(McFarlane et al., 2006Constantino et al., 2005;Tiwari et al., 2005Tiwari et al., 2010aTiwari et al., 2010bGillum et al., 2009;Cripe et al., 2010;Bair-Merrit et al., 2010;Humphreys et al., 2011;Taft et al., 2011;Miller,). These interventions included multiple components such as linking women to services, empowering women, educating women on parenting, and safety behaviours. The implementation of the interventions was heterogeneous in terms of who delivered the services (lay to professional) and setting (i.e. home, community, telephone and healthcare setting). There is evidence that intimate partner violence advocacy/empowerment interventions may reduce recurrence of intimate partner violence for some women, but there is insufficient evidence of an impact on quality of life or mental health outcomes. The strongest evidence came from three advocacy trials conducted in Hong Kong, which implemented similar empowerment-based interventions of brief duration to three (relatively small) samples of women -antenatal, community health centre based, and shelter based. 1 Of these three studies, the two evaluating the intervention in health-care settings reported benefit in some health and abuse outcomes. There remains uncertainty about the intensity required for advocacy/empowerment to have an effect outside of antenatal settings.
There are two important caveats, particularly in the context of developing an evidence base for international guidelines for health-care services. First, the strongest evidence for individual advocacy or support comes from trials of women in shelters, refuges, or safe houses with no direct connection to health-care settings, although there is more recent evidence from small-sample studies in antenatal care settings. Secondly, the evidence is based on studies in high-income countries, so other considerations need to be taken on board before making an extrapolation to the majority of the world's population.
Two studies investigated harm or distress caused by the topics of discussion, or breaches in confidentiality (McFarlane et al., 2006;Tiwari et al., 2005), and found none.

# from evidence to recommendations
After reviewing the evidence, the GDG thought there was some uncertainty about (i) the effectiveness of advocacy for quality of life and mental health outcomes, and (ii) extrapolation of benefit to women not residing in shelters, or women who are not pregnant. A vote was taken on recommendation 8 and the caveats were represented in the remarks.
(a) Information about exposure to violence should be recorded unless the woman declines, and this should always be conducted in a discreet manner (i.e. not with labels or noticeable markings that can be stigmatizing for women, especially when health-care professionals label them as "battered"). Women may not wish to have information recorded in their clinical history files, in the fear that their partner may find out. This concern will need to be balanced against the need to ensure adequate forensic evidence in circumstances where women decide to pursue a legal case.
(b) A woman should be helped to develop a plan to improve her safety and that of her children, where relevant.
(c) Attention should be paid to self-care for providers, including the potential for vicarious trauma (see Glossary).

# mother-child interventions evidence summary
Four studies were identified that evaluated mother-child interventions (Jouriles et al., 2001;Lieberman et al., 2005. Three randomized controlled trials (one involving follow-up of an earlier trial) of intensive interventions (at least 20 sessions) focusing on the mother-child dyad, found improvements in either the children's behaviour problems (Jouriles et al., 2001;Lieberman et al., 2005, their sense of competence and self-worth  and/or traumatic stress symptoms in children (Lieberman et al., 2005. One intervention showed reduction in some, but not other maternal post-traumatic stress symptoms (Lieberman et al., 2005. Of the two studies that considered maternal distress related to general psychiatric symptoms, one showed benefits  while the other showed no effect (Jouriles et al., 2009). A randomized controlled trial of community-provided trauma-focused CBT (TF-CBT; Cohen, 2011), with sessions provided to children and parents that focused exclusively on child outcomes, showed improvements in children's intimate partner violence-related PTSD and anxiety. This lends further support to the evidence for effectiveness of psychotherapeutic motherchild interventions, but specifically within the context of high-income countries.

# from evidence to recommendations
The GDG judged the evidence for specific intensive mother-child dyad interventions was sufficiently strong to recommend this intervention, although the applicability of this to low-income settings is uncertain.

# Other interventions
Studies evaluating expressive writing (Koopman et al., 2005) and yogic breathing (Franzblau et al., 2008) were reviewed. Both were community based without linkage to health-care services and were poor quality studies. The GDG did not regard the evidence as strong enough to make any recommendations. Figure 1 summarizes the care pathway for intimate partner violence and should help guide providers in their response to women survivors of intimate partner violence. Women who disclose any form of violence by an intimate partner (or other family member) or sexual assault by any perpetrator should be offered immediate support. This includes:
- ensuring consultation is conducted in private - ensuring confidentiality, while informing women of the limits of confidentiality (e.g. when there is mandatory reporting)
- being non-judgemental, supportive and validating what the woman is saying - providing practical care and support that responds to her concerns, but does not intrude
- asking about her history of violence, listening carefully, but not pressuring her to talk (care should be taken with the use of interpreters for sensitive topics)
- helping her access information about resources, including legal and other services that she might think helpful
- assisting her to increase safety for herself and her children, where needed - providing or mobilizing social support.
If health-care providers are unable to provide first-line support, they should ensure that someone else (within their health-care setting or another that is easily accessible) is immediately available to do so.

# Clinical care for survivors of sexual assault
Sexual assault is a potentially traumatic experience that may have a variety of negative consequences on women's mental, physical, sexual and reproductive health, meaning they may require acute and, at times, long-term care, particularly mental health care. In certain situations such as where there is a breakdown of law and order, armed conflict and postconflict, or displacement, sexual violence may be exacerbated. In prisons, mental health facilities and other settings where people are institutionalized, sexual violence also appears to be more prevalent. The gathering of forensic information is not covered by these guidelines, but is a critical element of post-rape care for those women who may want to pursue legal action. Please refer to the WHO Guidelines for medico-legal care for victims of sexual violence (2003) and the WHO/UNHCR Guidance on clinical management of rape guidelines ( 2004) and e-learning programme (2009) for further information on this.

# Interventions during the first
5 days after the assault 3.1.1 first-line support Recommendations 10 Offer first-line support to women survivors of sexual assault by any perpetrator (see also recommendation 1), which includes: y providing practical care and support, which responds to her concerns, but does not intrude on her autonomy y listening without pressuring her to respond or disclose information y offering comfort and help to alleviate or reduce her anxiety y offering information and helping her to connect to services and social supports.

# emergency contraception
Sexual assault may place women of reproductive age at risk of unwanted pregnancy. Although little research exists documenting the likelihood of pregnancy as a result of sexual assault, research conducted in the USA (namely, the National Women's Study) estimated a rape-induced pregnancy rate of 5% per rape of women of reproductive age (Holmes, 1996). Rape-induced pregnancy may be even more common among women who are sexually assaulted by intimate partners, with one small study finding that 20% out of 100 women sexually assaulted by intimate partners reported becoming pregnant as a result of this violence (McFarlane et al., 2005). Analysis of data from the WHO multi-country study on women's health and domestic violence against women shows that intimate partner violence is significantly associated with unwanted pregnancy and abortions (Pallitto et al., 2013).

# evidence summary
A search of the scientific literature did not identify any research studies that focused on the effects of emergency contraception used by survivors of sexual assault.
Given the absence of evidence for this particular PICOT question, and since there is no reason to believe that the effects of emergency contraception would differ in women who have been sexually assaulted compared to nonassaulted populations, four sets of evidencebased guidelines concerning emergency contraception for general populations of women were reviewed to help inform the recommendations, including those of:  (Cheng et al., 2008), a Cochrane Collaboration systematic review.
Comparison of these four guidelines, in terms of recommended drug regimens, shows that all groups except for Cheng and colleagues ( 2008) suggest that progestogen-only emergency contraceptive pills are the first choice of a drug regimen, with combined oestrogenprogestogen pills the secondary choice. By contrast, Cheng and colleagues ( 2008) recommend mifepristone as the first choice, followed by progestogen-only emergency contraceptive pills, and then a combined course of oestrogen-progestogen pills. It should, however, be noted that mifepristone in the dosage needed for emergency contraception is available in only four countries and is not recommended by WHO. All four groups agree that copper-bearing intrauterine devices (IUDs) may also be used as emergency contraception if not contraindicated. All four groups also agree that, if used, emergency contraception pills should be initiated as soon as possible after the unprotected sexual intercourse (or rape), to maximize effectiveness, with Cheng and colleagues (2008) specifying that this should occur within the first 24 hours. All groups also agree that these drugs may be initiated up to 5 days after the unprotected sexual intercourse (or rape), even though their effectiveness decreases with time. Two groups (the American College of Obstetricians and Gynecologists and the FIGO Working Group on Sexual Violence/ HIV) recommend that anti-emetics be used to prevent nausea when using a combined oestrogen-progestogen regimen as emergency contraception. By contrast, WHO (2004) recommends that anti-emetics should not be used routinely; instead, they recommend that this decision be based on clinical judgment and availability. Cheng and colleagues (2008) did not make a specific recommendation on anti-emetics, although they did find that the combined oestrogen-progestogen regimen was commonly associated with the side-effects of nausea and vomiting.
In addition, information from recent randomized controlled trials of uliprisal acetate was reviewed (including studies by Creinin et al., 2006;Glasier, 2010). These studies suggest that ulipristal acetate is as effective as (and possibly more effective than) levonorgestrel in pregnancy prevention when taken close to ovulation, with somewhat similar side-effects.

# from evidence to recommendations
The GDG accepted that guidance on emergency contraception for the general population would apply to women who had been sexually assaulted, and made recommendations accordingly, based on the review of the guidelines presented above. The FIGO and the American College of Obstetricians and Gynecologists classified the strength of their evidence and recommendations, but used different systems to do so. 1 The Cochrane review (Cheng et al, 2008) did not classify the strength of evidence. The strength of evidence in the following recommendations is based on the best assessment of the evidence provided in the guidelines reviewed.

# Recommendations 12 Offer emergency contraception to
survivors of sexual assault presenting within 5 days of sexual assault, ideally as soon as possible after the exposure, to maximize effectiveness.

# Quality of evidence: Moderate

# Strength of recommendation: Strong
Remarks (a) If used, emergency contraception should be initiated as soon as possible after the rape, as it is more effective if given within 3 days, although it can be given up to 5 days (120 hours).
13 Health-care providers should offer levonorgestrel, if available. A single dose of 1.5 mg is recommended, since it is as effective as two doses of 0.75 mg given 12-24 hours apart.

# HIv post-exposure prophylaxis: treatment and adherence
Sexual assault may be associated with the transmission of HIV. While the rate of sexual transmission of HIV is low (Boily et al., 2009), it is difficult to establish risk and there are several characteristics of sexual assaults (potential for tears, multiple perpetrators) that can affect this risk. Therefore, particularly in high-prevalence settings, there are strong ethical arguments to support the provision of post-exposure prophylaxis (PEP) for HIV infection.

# evidence summary: treatment
A search of the scientific literature did not identify any studies that examined the effects of HIV PEP for survivors of sexual assault that met all of the criteria specified in the PICOT question; however, four studies (Wiebe et al, 2000;Drezett, 2002;Garcia et al., 2005;Roland et al., 2012) were identified that focused on the effects of HIV PEP among survivors of sexual assault, even though they did not meet all the PICOT criteria. These studies were reviewed to shed some light on this important topic. Two of the four studies used prospective double cohort follow-up study designs to compare HIV seroconversion among survivors of sexual assault who were prescribed HIV PEP, with survivors of sexual assault who were not prescribed HIV PEP (Drezett, 2002;Garcia et al., 2005). The other two studies (Wiebe et al., 2000;Roland et al., 2012) used prospective cohort follow-up study designs to examine seroconversion among survivors of sexual assault who all were prescribed HIV PEP (these studies did not include a comparison group).
Each of these studies had important methodological limitations, such as lack of a comparison group, small sample sizes, and low follow-up rates. In addition, three of the studies (Wiebe et al., 2000;Garcia et al., 2005;Roland et al., 2012) included men, with no subgroup analysis that reported exclusively on the findings from women; an analysis of interest for this WHO review focused on female survivors of sexual assault. In addition, the research was conducted in only three countries: Brazil, Canada and South Africa, which limits the generalizability of the findings.
Results showed that only one of the two prospective double cohort follow-up studies found that, when compared to no HIV PEP (Drezett, 2002), HIV PEP reduced the probability of HIV seroconversion. In the two prospective cohort follow-up studies, seroconversion rates ranged from 0% to 3.7% (Wiebe et al., 2000;Roland et al., 2012).

# from evidence to recommendations: treatment
Since research on HIV PEP for survivors of sexual assault is limited, and as it is extremely unlikely that clinical trial studies will be undertaken on this issue (because of ethical and logistical reasons), recommendations need to be established by extrapolating the findings from other research, including animal studies and research on people other than survivors of sexual assault. For example, there is evidence from a case-control study that a short course of antiretroviral therapy effectively reduces HIV transmission following needle-stick exposure (Cardo et al, 1997). Thus, the recommendations developed for these guidelines considered other relevant guidelines concerning this topic (CDC 2010;WHO 2008).
The GDG discussed the generalizability of the evidence in all situations. Many women do not complete the 28 days of HIV PEP treatment required for it to be effective. This may be due to the side-effects of taking some of the drugs, and also related to the emotional consequences of the sexual assault. In addition, there are resource and logistic implications of providing HIV PEP. Taking this into consideration, the GDG questioned whether HIV PEP should be used routinely in locations where the prevalence of HIV is predicted to be low. There was a suggestion that health systems may wish to set a prevalence cut-off point, below which HIV PEP is not routinely offered. Additionally, in some circumstances, the risk of the individual perpetrator infecting the woman is low. It was therefore agreed that, particularly in low-prevalence settings, the risk should be considered in consultation with the woman before HIV PEP is offered.

# evidence summary: adherence
A search of the scientific literature did not find any studies that examined the effectiveness of interventions aimed at enhancing sexual assault survivors' adherence to HIV PEP, and that met all of the criteria specified in the PICOT question. However, one study was identified (Abrahams et al., 2010) that did examine this topic, even though it did not meet all the PICOT criteria (i.e. the study population included female children who were sexually assaulted, as well as adult women who were sexually assaulted, with no subgroup analyses conducted exclusively on the adult survivors). This study was reviewed to shed some light on this important topic.
Abrahams and colleagues (2010) examined whether psychosocial support via telephone would enhance adherence to HIV PEP. The study population included female child and adult survivors of sexual assault who were HIV negative when they presented at four sexual assault services in an urban and a rural site in South Africa. Participants were randomly allocated to receive a leaflet including an adherence diary, or the aforementioned plus psychosocial support by telephone. Adherence to HIV PEP was assessed during an interview that occurred 1-5 days after the 28-day period (the time during which the patients were supposed to take the HIV PEP).
Although this study used a strong research design to address the question, it also had several methodological limitations. One important limitation is that for nearly one third of participants the assessment of the primary outcome of interest (adherence to HIV PEP) was based on patients' reports of the amount of medication they did and did not take, a potentially unreliable measure, despite all study participants being provided with a diary to record when they took their medication. In addition, there were no subgroup analyses that reported exclusively on the findings from the adult participants, an analysis of interest for this review. Results showed that the intervention was not found to be effective. There were similar levels of extremely poor adherence to HIV PEP in both the intervention and comparison groups.

# from evidence to recommendations: adherence
Given that only one study was identified on this topic, and showed a negative outcome in that the intervention did not enhance adherence to HIV PEP, there is a lack of good research evidence on this topic on which to make recommendations.
The view of the GDG was that, while adherence is an important issue to address in relation to HIV PEP, the current evidence did not show an effective approach to enhancing adherence.  18 Adherence counselling should be an important element in PeP provision. y rape (penetration) took place less than 72 hours ago y HIV status of perpetrator positive or unknown y exposed individual not known to be HIV infected (need to offer HIV testing at time of consultation) y defined risk of exposure, such as: y receptive vaginal or anal intercourse without a condom or with a condom that broke or slipped; or y contact between the perpetrator's blood or ejaculation and mucous membrane or non-intact skin during the assault ; or y recipient of oral sex with ejaculation; or y the person who was sexually assaulted was drugged or otherwise unconscious at a time of the alleged assault and is uncertain about the nature of the potential exposure; or y the person was gang-raped.
(b) HIV testing is recommended prior to giving PEP but should not preclude PEP being offered. However, people with HIV infection, should not be given PEP and should be linked to care and provided with antiretroviral therapy.
(c) Health policy-makers should consider whether to include routine offer of HIV PEP in post-rape care, based on local prevalence, ethical and resource considerations.

# Post-exposure prophylaxis for sexually transmitted infections evidence summary
A search of the scientific literature did not identify any studies that examined the effects of STI PEP provided by health-care providers to women survivors of sexual assault. In light of the absence of evidence on this particular PICOT question, and since there is no reason to think that the effects of PEP for STIs would work differently in women who have been sexually assaulted compared to non-assaulted populations, health organizations/groups, including the Centers for evidence and recommendations Disease Control and Prevention (CDC) ( 2010) and the FIGO Working Group on Sexual Violence and HIV have based their recommendations concerning this topic on research evidence from other populations, expert opinion, or reports of expert committees. Therefore, these two recent sets of evidence-based guidelines concerning PEP for STIs were reviewed to help inform the recommendations.
Comparison of the CDC and FIGO guidelines on this topic found them to be in general agreement. Both recommend that survivors of sexual assault be provided with prophylaxis/treatment for Chlamydia, gonorrhoea and Trichomonas; however, the FIGO guidelines also recommend prophylaxis/ treatment for syphilis. Both the CDC and FIGO guidelines recommend that survivors of sexual assault receive vaccination for hepatitis B; however, the CDC guidelines also specify that this should be hepatitis B vaccination without hepatitis B immune globulin.

# from evidence to recommendations
Similar to the earlier section on emergency contraception, evidence was extrapolated from studies gathered from the general population, on the grounds that the effectiveness of STI PEP was unlikely to be different for survivors of sexual assault. The view of the GDG was that to test first and then treat for a positive result would necessitate a time lag, and risk the woman not returning for the result or treatment. Therefore, the GDG recommended presumptive treatment for STIs without prior testing.
As the recommendations below were based on the CDC guidelines (which did not include strength of evidence or strength of recommendation), and the FIGO guidelines (which did include this information), the strength of evidence in the recommendations below is based on the best assessment of the evidence provided in these guidelines.

# Psychological/mental health interventions 3.2.1 Interventions during the first days after the assault evidence summary
A search of the scientific literature identified nine studies examining the effects of mental health interventions provided by health-care providers for women survivors of sexual assault, with one of these studies meeting all of the PICOT question criteria (Echeburua et al., 1996) and eight of these studies (Rothbaum, 1997;Resick et al., 1988Resick et al., 2002Resick and Schnicke, 1992;Foa et al., 1991;Rothbaum et al., 2005;Galovski et al., 2009;Anderson et al., 2010) meeting most of the PICOT question criteria. Each of these studies was reviewed.
The nine studies evaluated 10 types of mental health therapies (assertion training, clinician assisted emotional disclosure, cognitive processing therapy, cognitive restructuring and coping skills, eye movement desensitization and reprocessing (EMDR) (see Glossary), prolonged exposure, progressive muscular relaxation, stress inoculation therapy, supportive counselling, and supportive psychotherapy and information). The first four and prolonged exposure and stress inoculation therapy represent different forms of cognitive behavioural therapy (CBT) (see Glossary). Seven studies focused on individually delivered therapies, while two studies focused on group therapies. The therapeutic interventions were delivered in sessions provided over a relatively short time (from 10 days to 12 weeks), with the total treatment time ranging from 5 to 18 hours.
The studies had both methodological strengths and limitations. In terms of strengths, six of the nine studies used a randomized controlled trial study design, one was a secondary analysis of data from a randomized controlled trial, and two were non-randomized controlled trials. Standardized assessment instruments were used in all studies, and multiple outcomes were assessed in most studies. The limitations included frequently not using a blinded assessment, having high loss to follow-up, no intent-to-treat analysis, and no control for potentially confounding variables. In addition, the studies often had multiple exclusion criteria, including psychological/ psychiatric co-morbidity, substance abuse/ dependence, and/or having experienced, or currently experiencing various forms of intimate partner violence and/or incest. Since many survivors of sexual assault have these types of problems, the generalizability of the findings of these studies to the greater population of survivors of sexual assault may be open to question. Moreover, most studies focused on survivors of sexual assault whose most recent assault had occurred at least 3 months before the study, with many of the study participants having been assaulted several years prior to the study. Although this inclusion criterion may be justified in that the investigators were trying to include only survivors of sexual assault whose levels of rape-related symptoms had not "naturally" decreased with time (or fulfilled the Diagnostic and statistical manual of mental disorders  diagnostic criteria for PTSD, which include for the exposure to have occurred at least 1-3 months previously), this inclusion criterion may limit the generalizability of the findings, especially for women who seek care soon after the assault. In addition, most of the studies had extremely small sample sizes. Finally, it should be noted that eight of the nine studies were conducted in the USA, and eight of the nine studies focused on clinic samples.
Taken together, the study findings appear to suggest that relatively brief mental health interventions, in particular several forms of CBT as well as EMDR, may improve the psychological health of many adult female survivors of sexual assault. Moreover, although these mental health interventions appear to be more helpful than receiving no treatment, the research does not unequivocally demonstrate that one particular type of therapy is clearly superior to all others.
Finally, given the few studies on this specific population and the variety of mental health interventions assessed (with some interventions being assessed in only one study), as well as the aforementioned methodological concerns, caution is urged in making recommendations on these limited study findings. Recommendations therefore also considered the wider body of research evidence concerning mental health interventions for all trauma victims, not just victims of sexual assault.

# from evidence to recommendations
The strength of recommendations for the effects of mental health interventions for the care of survivors of sexual assault is limited by the relatively few studies on this topic and the methodological limitations of this research. However, this research does provide a modicum of evidence that offering survivors of sexual assault particular types of mental health interventions, such as CBT (in particular, cognitive processing therapy, prolonged exposure, and stress inoculation therapy), as well as EMDR leads to improved psychological health, including improvement of PTSD. This is supported by more general evidence on the effectiveness of these approaches for trauma survivors.
The GDG discussed the availability of resources. Complex therapies, delivered by specialists, are likely to be unavailable or would involve a long waiting time in many countries, although the costs of such services must be considered against the social and human costs of sexual violence. It is noted that there is a move to simplify and test these therapies in general health settings (Rahman et al.'s 2008 study on CBT by "lady health workers" for maternal depression). This approach needs to be tried and evaluated beyond research settings, which tend to involve higher levels of supervision and oversight to prove efficacy.
In addition to the evidence summarized above, the GDG reviewed the WHO (2011) publication Psychological first aid, which provides guidance for crisis situations, the WHO (2010) mhGAP intervention guide for treating mental, neurological and substance use disorders for nonspecialist health settings, and the WHO ( 2009) guidelines for pharmacological treatment of mental disorder in primary care, which aim to enhance the provision of mental health services at primary care level. Psychological first aid is a very basic form of psychological support (see recommendations 1 and 10), suitable for primary care level, with limited or no referral possibilities.
Recommendations 21 Continue to offer support and care described in recommendation 10.  2010). Women with mental health and substance abuse problems may be at greater risk of rape than other women, so there is likely to be a disproportionate burden of pre-existing mental health and substance abuse problems among rape survivors. Similarly, pre-existing traumatic events (e.g. sexual abuse in childhood, intimate partner violence, war-related trauma, etc.) should be considered.
(c) It is important to recognize that sexual assault is sometimes perpetrated by a person the woman lives with. This can include not just a partner but other family members, such as a stepfather, in-law, friend of the family, or other.
(d) Most women should have access to group or individual lay support, ideally based on the principles of Psychological first aid (WHO, 2011).
Figure 2 shows the care pathway for a woman presenting for sexual assault and should help guide the providers' response to a survivor of sexual assault.

# Training of health-care providers on intimate partner violence and sexual violence

# evidence summary
Evidence was searched for the y effects of training interventions for healthcare providers on intimate partner violence and sexual violence that improves: (i) providers' skills/ability and/or (ii) outcomes for women y elements of training courses that improve the skills and ability of providers to respond appropriately to women exposed to violence and/or improve outcomes for women y effectiveness of training for health-care providers on intimate partner and sexual violence at pre-qualification level.

# training interventions for intimate partner violence
The review of the evidence for the effects of training health-care providers in intimate partner violence found that most studies showed some improvement in knowledge of providers following a training intervention. However, there is little support for interventions where health-care providers are only trained in the identification of intimate partner violence, without adequate training in care and referral (Coonrod et al., 2000). Yet many interventions currently focus only on training health-care providers in identification. Interventions involving training in multicomponent aspects of intimate partner violence (identification, clinical skills, documentation and provision of referral) that used interactive techniques, appear to improve identification rates and changes in attitude and behaviour of health-care providers. Very few studies evaluated the impact of training on outcomes for women survivors of intimate partner violence (Campbell et al., 2001;Dubowitz et al., 2011;. Most of the evidence comes from highincome countries, with fewer, lower quality studies of the effectiveness of training interventions in low-and middle-income countries (PRIME, 2002;Grisurapong, 2004;Bott et al., 2005). In the studies carried out in high-income countries, there was some support in favour of brief multicomponent (20-minute to 1.5-day training) interactive, multimediabased interventions that involved discussions, simulations and role-plays to train health-care providers in all aspect of intimate partner violence, including identifying, managing and providing links to agencies in the community. However, there is no conclusive evidence on what impact these interventions have on attitudes and beliefs regarding intimate partner violence, referral to services for intimate partner violence, or patient outcomes. The latter are rarely measured in evaluations of training.
There is some evidence that training in intimate partner violence, alongside other changes in systems of care and referral pathways, may be more beneficial in improving identification, and possibly even outcomes, for women survivors of intimate partner violence than training on its own (Lo Fo Wong et al., 2006;Garg et al., 2007).
Most studies were of low to very low quality and did not report on lasting effects of the interventions.

# training interventions for sexual assault
Only four studies were identified (Parekh et al., 2005;McLaughlin et al., 2007;Donohoe, 2010;Milone et al., 2010) that focused on examining the effects of health-care provider training in sexual violence against women. Each study focused on outcomes of the healthcare providers who were trained, but none examined whether this training translated into improved outcomes for the survivors of sexual assault. Moreover, each study had one or more important methodological limitation, such as the lack of a comparison group, no assessment made either before or after the training, lack of psychometrically sound assessment tools, and extremely small sample sizes. In addition, even though the research was done in three countries (Australia, UK and USA), no research studies on training in low-income countries were identified. Given this limited evidence base, no firm conclusions can be drawn concerning the effects of training health-care providers in responding to sexual violence against women. However, the results from these studies do indeed provide some evidence that training healthcare providers in sexual assault against women Box C. emergency contraception - Offer levonorgestrel, if available. A single dose of 1.5 mg is recommended, since it is as effective as two doses of 0.75 mg given 12-24 hours apart. - If levonorgestrel is nOt available, the combined oestrogen-progestogen regimen may be offered, along with antiemetics if available. - If oral emergency contraception is not available and it is feasible, copperbearing intrauterine devices (Iuds) may be offered to women seeking on-going pregnancy prevention. taking into account the risk of stIs, the Iud may be inserted up to 5 days after sexual assault for those who are medically eligible (see WHO medical eligibility criteria, 2010).

# Box d. stI PeP
Offer prophylaxis/presumptive treatment for:
- Chlamydia - gonorrhoea - trichomonas - syphilis, (depending on the prevalence in the geographic area).
the choice of drug and regimens should follow national guidance.
Offer Hepatitis B vaccination without hepatitis B immune globulin as per national guidance.
- take blood for hepatitis B status prior to administering the first vaccine dose. - If immune, no further course of vaccination is required.
If a woman comes after the time required for emergency contraception (5 days), emergency contraception fails or the woman is pregnant as a result of rape, abortion should be offered, as per national law.
Psychological support up to 3 months post-trauma - Continue to offere first-line supportand care as described above.
- Unless the person is depressed, has alcohol or drug use problems, psychotic symptoms, is suicidal or self-harming or has difficulties functioning in day-to-day tasks, apply "watchful waiting" for 1-3 months after the event. Watchful waiting involves explaining to the woman that she is likely to improve over time and offering the option to come back for further support by making regular follow-up appointments. - If the person is incapacitated by the post-rape symptoms (i.e. she cannot function on a day-to-day basis), arrange for cognitive behaviour therapy (CBT) or eye movement and desensitization and reprocessing (EMDR), by a health-care provider with a good understanding of sexual violence. - If the person has any other mental health problems (symptoms of depression, alcohol or drug use problems, suicide or self-harm) provide care in accordance with the WHO mhGAP intervention guide (WHO, 2010).
Interventions from 3 months post-trauma - Assess for mental health problems (symptoms of acute stress/PTSD, depression, alcohol and drug use problems, suicidality or self-harm) and treat depression, alcohol use disorder and other mental health disorders using the mhGAP intervention guide (WHO, 2010), which covers WHO evidence-based clinical protocols for mental health problems. - If the person has been assessed as experiencing post-traumatic stress disorder (PTSD), arrange for PTSD treatment with cognitive behaviour therapy or eye movement and desensitization reprocessing. Offer all women stI prophylaxis/treatment (see Box d).
nO do injuries require urgent treatment?
Offer first-line support to women survivors of sexual assault by any perpetrator, which includes:
- providing practical care and support, which responds to her concerns, but does not intrude on her autonomy - listening without pressuring her to respond or disclose information - offering comfort and help to alleviate or reduce her anxiety - offering information and helping her to connect to services and social supports. take a complete history, recording events to determine what interventions are appropriate, and conduct a complete physical examination (head-to-toe including genitalia). b The history should include:
- the time since assault and type of assault - risk of pregnancy - risk of HIV and other STIs - mental health status. Provide written information on coping strategies for dealing with severe stress (with appropriate warnings about taking printed material home if an abusive partner is there). Psychological debriefing should nOt be used. either a victim or a perpetrator. This needs to be addressed in their training.
31 Health-care providers offering care to women should receive in-service training on violence against women, ensuring it: y enables them to provide first-line support (see recommendations 1 and 10) y teaches them appropriate skills, including: y when and how to enquire about violence y the best way to respond to women (refer to sections 2, Identification and care for survivors of intimate partner violence and 3, Clinical care for survivors of sexual assault) y how to conduct forensic evidence collection where appropriate (see WHO, 2003;WHO/unHCR, 2004;) y addresses:
y basic knowledge about violence, including laws that are relevant to victims of intimate partner violence and sexual violence y knowledge of existing services that might offer support to survivors of intimate partner violence and sexual violence (this could be in the form of a directory of community services) y inappropriate attitudes among healthcare providers (e.g., blaming women for the violence, expecting them to leave immediately, etc.), as well as their own experiences of partner and sexual violence.

# from evidence to recommendations
Although evidence was not found on the impact of training from low-and middle-income countries, consistent impact on knowledge, and, to some extent, on behaviours of healthcare providers, was seen in studies from high-resource settings. The GDG agreed that training of health-care providers in intimate partner violence and sexual assault needs to be added to the curriculum of basic professional education and, at a minimum, provided in the form of continuing education of those providers most likely to encounter women.

# Health-care policy and provision
Evidence was searched for the following questions:
y "What are the effects of health system-level programmes/services for women survivors of partner violence?" y "What are the effects of the components/ features of health system-level interventions/ programmes for women survivors of partner violence?" y "What are the effects of integrating a sexual assault nurse examiner (SANE) programme, or another type of sexual assault programme, into a health-care setting, on the care of sexual assault survivors?"

# evidence summary
Health system-level programmes or interventions that could deliver care for intimate partner violence and/or sexual assault survivors, effectively and efficiently, were identified, particularly keeping in mind the needs in resource-poor settings. As most of the published evidence on health-system response to intimate partner violence and sexual assault came from high-income countries, a separate search of the grey literature was carried out, to identify practices and programmes that had not been published in peer-reviewed journals.
The evidence reviewed here overlapped substantially with that for training interventions, particularly as no study identified which components of multi-intervention studies (which included training) were found to be effective.
In high-income countries, there was some evidence indicating that a system-level intervention involving staff training does increase referral to other services. Five out of 10 studies (Coyer et al., 2006;Fanslow et al., 1998Fanslow et al., 1999Harwell et al., 1998;Spinola et al., 1998;McCaw et al., 2001;Munoz et al., 2001;Ramsden and Bonner, 2002; reported an increase in referral rates. A recent cluster randomized controlled trial in general practices in the UK presented the strongest evidence of increased referrals to, and appointments with, specialist intimate partner violence agencies, as well as increased rates of disclosure.
In studies with positive findings, it was difficult to identify the actual factor or component responsible for the positive outcome, since interventions usually comprised various small components that were not evaluated independently. Studies also differed in the way interventions were constituted and offered, making comparisons across interventions difficult. There is a need to understand the reasons why projects showed significant improvements or otherwise.
Many of the studies were of low quality, owing to study design (often observational), small sample sizes, or a lack of sample sizes being presented, high loss to follow-up of participants or short follow-up period, inadequate presentation of data (e.g. in graphs without the presentation of actual percentages), among other factors. Overall, there is a shortage of robust evaluations of the effectiveness of health-system interventions for intimate partner violence and sexual assualt. Despite the work that has been done, there remains insufficient evidence that specific policies, protocols or models of care are more effective than others in the delivery of care to women exposed to intimate partner violence and sexual violence.
In resource-poor countries, various models of care were described. The models for service delivery often depended on the availability of financial and human resources, and varied across settings. It was apparent that "one-stop crisis centres" were a popular approach, albeit not well evaluated, although these centres were constituted very differently in different countries. Almost all had a permanent nurse, who sometimes had other service obligations, but the involvement of other staff differed and included having a doctor, counsellor, advocate, psychiatrist or psychologist on-call or on-site. The role of NGOs also varied, from initiating the service to delivering it. Linkages with other government agencies were in some instances very formal and saw them playing a central role, but more often this occurred through the development or improvement of referral systems. The involvement and linkages with the police, social services and legal services also varied in "one-stop crisis centre" models. In many instances, the greatest challenge reported was in obtaining management and administrative support, mostly linked to financial support, especially for the longterm sustainability of the centres. There was not always a smooth replication of "good" models of service delivery, even within the same country. In addition, low-and middleincome countries face the challenge of not having sufficient skilled personnel, especially for counselling, mental health and advocacy/support services. Where staff, such as counsellors, social workers, psychologists and psychiatrists, are in short supply, there is a bigger dependence on NGOs. Table 1 summarizes the advantages and disadvantages of different sites for delivering care to survivors of intimate partner violence.
With regard to integrating a SANE or other type of sexual assault care programme  (Derhammer et al., 2000;Crandall et al., 2003;Kim et al., 2009;Sampsel et al., 2009) were identified that focused on this. Although each study had its strengths, they all had important methodological limitations (such as small sample sizes, low response rates, and much missing data on important variables). Moreover, three were conducted in North America (one in Canada and two in the USA), with only one from a middle-income country (South Africa). They all used a historical comparison group (comparing health-care services for survivors of sexual assault, before and after implementation of a new programme). The results from these studies were generally consistent and positive. They suggest that integrating sexual assault care programmes into health-care settings leads to greater percentages of sexual assault patients receiving potentially vital health-care services, including emergency contraception, STI prophylaxis, HIV counselling and PEP, and post-care referrals. Integration of SANEs into health-care settings does not always result in nurses becoming more involved in the sexual assault examination. Where they are involved, however, integration of SANEs into health-care settings appears to enhance the collection of forensic evidence often required for successful prosecution of perpetrators of sexual assault.

# from evidence to recommendations
The GDG discussed the evidence and reached the conclusion that there is no evidence to accept or refute any one model of intimate partner violence or sexual assault service provision. There is also evidence that a model that appears to be working effectively in one setting may be rapidly adopted in another site and not necessarily be effective. This has been true of "one-stop crisis centres". Therefore, the advantages and disadvantages of the various models have been summarized to help policymakers with decisions, taking into account local human and financial resources (see Table 1). In addition, an attempt was made to answer the following questions to help guide policy-makers when making decisions: (b) Offering vertical stand-alone services may be difficult to sustain and have potential harmful effects. For instance, there might be a risk that a currently under-staffed mental health service would be further weakened if it had to provide services specifically for victims of violence, rather than ensuring that all clients (including survivors of violence) get the best possible care. c) Providing support to the carers and the possibilities of debriefing should also be part of the health-systems response, although this requires additional human resources. It is also important for the health services to meet regularly with other agencies such as police or social workers, to ensure that there is coordination and coherence across services and that referrals are working effectively.

# Box 3 Minimum requirements for a health sector response to violence against women
Policies and protocols local policies and protocols defining roles and responsibilities, and procedures related to identification and management of survivors need to be developed and implemented (with appropriate training and continual support).
management support/finance management backing, often with financial support, is important, especially for the long-term sustainability of the integration of violence against women issues.
Comprehensive care ensure the provision of all aspects of medico-legal care either by provider/linked providers in health services, or through the support of ngOs or communitybased organizations (CBOs) or community efforts, in a way that minimizes the number of contacts required.
links with CBOs/ngOs Build relationships with local ngOs and community-based organizations (CBOs). (It should be noted that it is a state responsibility to ensure the provision of services, so this should not rely exclusively on ngOs and CBOs).
Intersectoral collaboration establish clear working protocols, including the referral pathway of survivors, between services offered by the same facility or by different sectors, and establish regular (monthly) meetings to ensure coordination.
Resource material ensure the availability of some resource material (posters, pocket cards and/or leaflets).
surveillance and recording develop systems for maintaining records and conducting surveillance that are confidential and do not put women in any risk. (b) One-stop centres, where appropriate, are best located within health services, where the priority for provision of services is women's health rather than being based on legal outcomes. They appear to be best suited for areas with high population density, whereas integrated services within or across health facilities may be more cost effective in rural areas.
(c) Whatever model is used, it should aim to reduce the number of services and providers that a woman has to contact (and tell her story to), and facilitate access to services she may need, in a manner that respects her dignity and confidentiality and prioritizes her safety.
(d) Violence against women is also a violation of a woman's human rights. Policies and laws need to be revised to ensure they do not discriminate against women and that they adequately penalize acts of violence, including those that take place within the home.

# Mandatory reporting of intimate partner violence
Evidence was searched for the question: "What are the effects on women and their children of mandatory reporting of intimate partner violence to the police?"

# evidence summary
In total, 23 studies were reviewed, although only two studies (Sachs et al., 1998;Glass et al., 2001) attempted to measure the impact of mandatory reporting quantitatively. Five studies (Tilden et al., 1994;Rodriguez et al., 1998;Gerbert et al., 1999;Feldhaus et al., 2003;Smith et al., 2008) aimed to ascertain views of healthcare providers, while 16 attempted to obtain the perspective of women. Two studies quantitatively assessed the impact of introducing laws on mandatory reporting for intimate partner violence. Of these, a study (Sachs et al., 1998) that assessed the impact of mandatory reporting by healthcare professionals on police dispatches to medical facilities in response to intimate partner violence, reported no significant effect of the mandatory reporting on the number of police dispatches to the facilities. In another study in the USA, the medical records of 36 acutely abused patients were reviewed. Notification to the police was the most consistently documented intervention for intimate partner violence in the medical records. However, only one in four cases was referred to domestic violence community resources such as shelters and hotlines.
The remaining studies attempted to obtain the views of health-care providers and women on the impact of mandatory reporting laws, as well as on barriers and facilitators to mandatory reporting. From the perspective of healthcare providers, the advantages of mandatory reporting include improved collection of statistics, prosecution of the perpetrator and improved physician responsiveness.
Concerns shared by health-care providers included the time and resource requirements, the possibility that women may be discouraged from disclosing information, confidentiality and autonomy being compromised, the risk of retaliation, and the consequences of unsuccessful prosecutions.
From the perspective of the women, the advantages include: enabling them to get help while taking away the responsibility to report it themselves, making them feel less alone and less to blame, teaching partners the seriousness of abuse, and a potentially positive interaction with the police, with the incident being on record if needed in the future.
Women's concerns included the risk of retaliation, the fear their children would be taken away, anxiety about interacting with a social worker or other people in authority, being victimized by the health system, and being left with bills to pay as a result of the intimate partner violence report, as well as worries over autonomy and confidentiality.
While a number of women supported mandatory reporting, there appears to be an equally large number who do not. In particular, abused women appear to be against mandatory reporting, especially if it involves the police. Women in these studies suggested that the decision about reporting should be up to the woman; and that the safety of the woman and her children should be the first priority. Furthermore, recovery should focus on healing for the victims, including through counselling. If a restraining/protection order is in place, and the partner presents at the health visit, the relevant authorities should be called.

# from evidence to recommendations
The evidence does not support mandatory reporting of intimate partner violence to police because it can impinge on women's autonomy and decision-making. 1 While some women recognize there may be some benefits to legal action being taken on their behalf, it does not appear to be the preference for abused women. It is important to note that there may be differences between the reporting mandated by law and professional obligations/ codes of conduct for health-care providers that mandate confidentiality and "do no harm". Health-care providers need to understand their legal obligations (if any), as well as their professional codes of practice, to ensure that women are informed fully about their choices and limitations of confidentiality where this is the case.
37 mandatory reporting of intimate partner violence to the police by the health-care provider is not recommended. However, health-care providers should offer to report the incident to the appropriate authorities (including the police) if the woman wants this, and is aware of her rights.
Quality of evidence: Very low Strength of recommendation: Strong
38 Child maltreatment and life-threatening incidents must be reported to the relevant authorities by the health-care provider, where there is a legal requirement to do so.
a) It is noted, however, that there is growing consensus that countries with mandatory child reporting laws should allow children and families greater access to confidential services where they can receive support on a voluntary basis.
b) Furthermore, the usefulness of mandatory reporting is particularly questionable in situations where there is no functioning legal or child protection system to act on a report. 2 Quality of evidence: Very low Strength of recommendation: Strong

# general remark
(a) The issue of mandatory reporting is intertwined with that of child protection (which was outside of the scope of these guidelines).

# evidence and recommendations
The GDG identified important knowledge gaps that need to be addressed through research.
In general, in these guidelines, many of the recommendations are based on evidence that has been labelled "very low" or "low" quality, indicating that further research is needed.
Even in some of the areas where there was better quality evidence, research evidence was unavailable to address certain aspects of the topic.

# Research gaps based on guideline questions
The GDG identified the following gaps in the research. These were discussed at the meeting and agreed upon during the GDG review of the draft, but they do not represent a comprehensive assessment of research gaps. for child maltreatment) that include a focus on women experiencing intimate partner violence and measure intimate partner violence as a primary outcome should be implemented. y Mother-child interventions that have been shown to be effective in high-income settings need to be studied in low-resource settings, with alternatives to intensive psychotherapy identified and studied further.

# Safe shelter
y Options for safe shelter should be evaluated, particularly in resource-poor settings.
Clinical care for survivors of sexual assault Psychological/mental health interventions y For women survivors of sexual assault, there is a need for studies of psychological interventions that are specific to this population, allow for subgroup analysis of this group when the population is a mix of trauma survivors, and take into consideration issues of co-morbidity, which are common in this population. y There is a need to evaluate the provision of CBT by non-specialists and to study modalities of delivering CBT in different contexts.
HIV post-exposure prophylaxis y Studies that assess different interventions to promote adherence to HIV PEP should be carried out, including looking at the impact of different modalities of providing PEP (e.g. starter pack with weekly supplies versus 28 days, at first contact).

# Dissemination and implementation of the guidelines
The ultimate goal of these guidelines is to improve the quality of care and health outcomes related to violence against women. Hence, dissemination and implementation of the guidelines by the international community, ministries of health and local health-care services is crucial. RHR has adopted a formal knowledge-to-action framework for the dissemination, adaptation and implementation of guidelines. In addition to this framework, a list of priority actions will be established to enable WHO and other partners to foster their dissemination and implementation.

# Guideline dissemination
The recommendations in these guidelines will be disseminated through a broad network of international partners, including WHO country and regional offices, ministries of health, WHO collaborating centres, professional associations; other United Nations agencies, particularly UNFPA and UN Women; and NGOs. They will also be published on the WHO web site and in the WHO Reproductive Health Library, where they will be accompanied by an independent critical appraisal. In addition, a policy brief aimed at a wide range of policy-makers, programme managers and clinicians will be developed and disseminated through WHO country offices and its respective partners.
A clinical handbook will be developed based on the recommendations in this guideline for health-care providers, as well as policy briefs for policy-makers.

# Guideline implementation
The successful introduction into national programmes and health-care services of evidence-based policies related to violence against women relies on well-planned and participatory consensus-driven processes of adaptation and implementation. These may include the development or revision of existing national guidelines or protocols.
The recommendations contained in these guidelines should be adapted into a locally appropriate document that can meet the needs of each country and health service, while taking the human and financial resources available into account. This needs to include national policy as well as local clinical guidance. In this context, modifications may be limited to conditional recommendations, and justification for any changes should be made in an explicit and transparent manner.
In addition, a framework should be established to ensure that an enabling environment is created for use of the recommendations and that the health-care practitioner is supported in the use of evidencebased practices. In this process, the role of local professional societies is also important, and an all-inclusive and participatory process should be encouraged.

# Monitoring and evaluating implementation of the guidelines
Ideally, implementation of the recommendations should be monitored at a health-facility level. Interrupted time-series of clinical audits or criterion-based clinical audits could be used to obtain relevant data related to changes in the care that is given to women survivors of violence. Clearly defined review criteria and monitoring and evaluation indicators are needed and could be associated with locally agreed targets. In this context, Violence against women and girls: a compendium of monitoring and evaluation indicators by Measure Evaluation provides a comprehensive list of indicators that can be considered for health programmes addressing violence against women and girls (Bloom, 2005

# Updating of the guidelines
These guidelines will be updated in 5 years, or following the identification of new evidence that shows a need for changing the recommendations. WHO welcomes suggestions regarding additional questions for inclusion in future guidelines. Please e-mail your suggestions to Dr Claudia Garcia-Moreno at garciamorenoc@who.int
World Health Organization. mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings. Geneva, World Health Organization, 2010c

# declaration of interests of the guideline development group
All members submitted the Declaration of Interests form. At the beginning of the meeting, all members verbally declared their interests to the group. This is not a field where there are significant commercial interests; however, there are strong publicly stated opinions and research interests, including funded grants. It is also a small field and the authors of many of the papers being reviewed were part of the GDG. Therefore, prior to each topic being discussed, members declared if they were: y an investigator in any of the studies being discussed y conducting any research currently in the area y known to hold a stated public opinion.
The Chairman had a stated public opinion regarding universal screening and therefore did not chair the screening discussion. Many GDG members were researchers who had participated in research trials under discussion, during which they acted as knowledge experts but did not take part in the discussion per se. Otherwise, full participation was considered as appropriate. Other participants did not present any potentially conflicting interest.

# III. List of full reviews and evidence tables
The standardized criteria used in grading the evidence and the GRADE tables are not included in this document. The full reviews plus all evidence tables are available. A list of the separate documents (available upon request from rhr@who.int) is given below.