Violence against women is a major public health and human rights issue, 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 short and long term (Campbell, 2002;Garcia Moreno et al, 2005;Ellsberg et al, 2007;Bott et al, 2012).
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.
Women who have been subjected to violence often seek health care, including for their injuries, even if they may not disclose the associated abuse or violence, and a health-care provider is likely to be the first professional contact for survivors of intimate partner violence or sexual assault. Women also identify health-care providers as the professionals they would most trust with disclosure of abuse (Feder et al, 2006) Health professionals can provide assistance to these women by facilitating disclosure, offering support and referral, gathering forensic evidence -particularly in cases of sexual violence -or by providing the appropriate medical services and follow-up care.
Health-care providers who come into contact with women facing violence need to be able to recognize signs of it, and respond appropriately and safely. Individuals exposed to violence require comprehensive, gender-sensitive health-care services that address the physical and mental health consequences of their experience and aid their recovery. Women mayalso require crisis intervention services in order to prevent further harm. In addition to providing immediate medical services, the health sector is potentially a crucial gateway to providing assistance through referral pathways to specific services for violence against women-or to other aid that women may require at a later date, such as social welfare and legal aid. In all circumstances, there is a minimum first-line supportive response required and the first recommendation below outlines this minimum.
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. Furthermore, services should aim to be, "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". 1 This document summarizes Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines, the World Health Organization (WHO), 2013 publication, 2 developed by an international group of experts following a thorough review of evidence. It contains evidence-based recommendations for the introduction of policies into health services and programmes to improve responses within the health sector to violence against women. Each recommendation is classified as either "strong" or "conditional", on the basis of the generalizability of benefit across different communities and cultures, 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. Further clarifications are noted below some recommendations as remarks.
It is understood that these recommendations 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.
1 CEDAW General Recommendation 24, para 22 2 For full document, see / Who are these recommendations for?
The recommendations 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. They also seek to make health-care providers and policy-makers in charge of planning, funding and implementing health services and professional training more aware of violence against women, to encourage an evidence-informed health-sector 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.

# Providing first-line women centred-care Recommendation 1
Women who disclose sexual assault by any perpetrator or violence of any form by an intimate partner or other family member should be offered immediate support.
Health-care providers should, as a minimum, offer first-line support when women disclose violence.

# This includes:
- being non-judgmental, 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, without pressuring her to talk (care should be taken during sensitive topics when interpreters are involved)
- providing 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.
It is important to ensure:
- that the consultation is conducted in private - confidentiality, while informing women of the limits of confidentiality, for example if there is mandatory reporting.
(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 decisionmaking. 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.
(a) A minimum condition for health-care providers to ask women about violence is that it is safe to do so (i.e. the partner is not present); they must be trained on the correct way to ask and on how to respond to women who disclose violence (see Box 1 on minimum requirements). This should at least include first-line support for intimate partner violence (see recommendation 1).
(b) Providers need to be aware of, and knowledgeable about, resources available to refer women to when asking about intimate partner violence.  The following recommendations were made:

# Psychological interventions
Women with a pre-existing diagnosed or partner violence-related mental disorder (such as depressive disorder or alcohol use disorder) who are experiencing intimate partner violence, should receive mental health care for the disorder in accordance with the WHO mhGAP Intervention guide 2010a delivered by health-care professionals with a good understanding of violence against women.
Remarks a) Use of psychotropic medications in women who are either pregnant or breastfeeding requires specialist knowledge and is best provided in consultation with a specialist where available. For details on management of mental health issues in these two groups please see the mhGAP guidelines (WHO, 2010a).

# Recommendation 6
Cognitive behavioural therapy (CBT) or eye movement desensitization and reprocessing (EMDR) interventions, delivered by health-care professionals with a good understanding of violence against women, are recommended for women who are no longer experiencing violence but are suffering from PTSD.

# Advocacy/empowerment interventions

# Recommendation 7
Women who have spent at least one night in a shelter, refuge, or safe house should be offered a structured programme of advocacy, support, and/or empowerment.

# Remarks a)
The extent to which this may apply to women leaving the household in situations where shelters do not exist is not clear.
(b) This may be considered for women disclosing intimate partner violence to healthcare providers, although the extent to which this may apply in circumstances outside of shelters is not clear and should be researched further.
(c) In populations where the prevalence of intimate partner violence is high, priority should be given to women experiencing the most severe abuse. (The guideline development group did not agree whether this should extend to severe psychological abuse.) (d) Interventions should be delivered by trained health-care or social care providers or trained lay mentors, tailored to the woman's personal circumstances and designed to combine emotional support and empowerment with access to community resources.

# Recommendation 8
Pregnant women who disclose intimate partner violence should be offered brief to medium-duration empowerment counselling (up to 12 sessions) and advocacy/ support, including a safety component, offered by trained service providers where health-care systems can support this. The extent to which this may apply to settings outside of antenatal care, or its feasibility in low-or middle-income countries, is uncertain.
(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. Women's preferences need to be balanced against the need to ensure adequate forensic evidence in circumstances where women decide to pursue a legal case, and the reporting policies at each health-care facility.
(b) A woman should be helped to develop a plan to improve her safety and that of her children, when relevant.
(c) Attention should be paid to self-care for providers, including the potential for vicarious trauma (see Glossary).

# Mother -child interventions

# Recommendation 9
Where children are exposed to intimate partner violence at home, a psychotherapeutic intervention, including sessions with and without their mother, should be offered, although the extent to which this would apply in low-and middle-income settings is unclear.
(a) The cost of intensive psychotherapeutic interventions focusing on the mother-child, and lack of providers trained to deliver this type of intervention, makes it challenging to implement them in resource-poor settings.

# Figure 1. Care pathway for intimate partner violence (IPV = intimate partner violence)
Box B -First-line support 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. 3.1 Interventions during the first five days after the assault (see Figure 2, page 15)
Offer first-line support to survivors of sexual assault by any perpetrator.
- providing practical care and support, which responds to the woman's 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.

# Recommendation 11
Take a complete history, recording events to determine which interventions are appropriate, and conduct a complete physical examination, i.e. head-to-toe and including genitalia. 3 The history should include:
- time since assault and type of assault
- risk of pregnancy
- risk of HIV and other STIs
- mental health status.

# Emergency contraception
The following recommendations were made:

# Recommendation 12
Offer emergency contraception to sexual assault survivors presenting within five days of sexual assault, ideally as soon as possible after the exposure. to maximize effectiveness.
(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 ( 120hours).

# Recommendation 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.
- If levonorgestrel is NOT available, the combined oestrogen-progestogen regimen may be offered, along with anti-emetics if available.
- If oral emergency contraception is not available and it is feasible, copperbearing intrauterine device (IUDs) may be offered to women seeking ongoing pregnancy prevention. Taking into account risk of STIs, the IUD may be inserted up to five days after sexual assault, for those who are medically eligible (see WHO (2010b), Medical eligibility criteria for contraceptive use).
(a) The GDG discussed some of the contraindications and side-effects of the drugs. Emergency contraceptive pills on the market are extremely safe and well tolerated and meet the criteria for over-the-counter provision.
(b) Ulipristal acetate is a relatively new drug that appears to be as effective as, or more effective than, levonorgestrol. While the side-effect profile seems similar to that of levonorgestrol, it is not yet included in the WHO essential medicines list (WHO, 2011), although further evidence may change this. Levonorgestrel remains less expensive and is available in most settings.
(c) The higher risk of STIs following rape should be considered if using a copper-bearing IUD. IUDs are an effective method of emergency contraception and should be made available to women seeking emergency contraception.
(d) A pregnancy test is not required, but if one was done and the result was positive, emergency contraception would not be necessary or effective.

# Recommendation 14
If a woman presents after the time required for emergency contraception (five days), emergency contraception fails, or the woman is pregnant as a result of rape, safe abortion should be offered, in accordance with national law.
(a) Where abortion is not permitted, other options such as adoption should be explored with the woman.

# Post-exposure prophylaxis (PEP) for HIV
Sexual assault may be associated with the transmission of HIV. While the rate of sexual transmission of HIV is estimated at less than 0.01% per sexual contact, it is difficult to establish risk and there are characteristics of sexual assault (potential for tears, multiple perpetrators) that can increase this risk. Therefore, in settings with high HIV prevalence, there are strong ethical arguments to support the provision of PEP for HIV infection.
The following recommendations were made:

# Recommendation 15
Consider offering HIV PEP for women presenting within 72 hours of sexual assault.
Use shared decision-making with the survivor to determine whether HIV PEP is appropriate (see WHO/ILO guidelines on post-exposure prophylaxis (PEP) to prevent HIV infection, (WHO, 2007).
(a) PEP should be initiated as soon as possible after the assault, ideally within a few hours and no later than 72 hours after the exposure.
(b) In low-prevalence settings, policies on offering routine HIV PEP will need to consider the local context, resources and opportunity and other costs of offering it.

# Recommendation 16
Discuss HIV risk to determine the use of PEP with the survivor, including:
- HIV prevalence in the geographic area
- limitations of PEP 4
- perpetrator HIV status and characteristics, if known
- assault characteristics, including the number of perpetrators
- side-effects of the antiretroviral regime used in the PEP regimen
- likelihood of the HIV transmission.

# Recommendation 17
If HIV PEP is used:
- start 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.
(a) The choice of PEP drugs should be based on the country's first-line antiretroviral regimen for HIV.

# Recommendation 18
Adherence counselling should be an important element in PEP provision. Healthcare providers should be aware that adherence is particularly difficult for survivors of sexual assault, as it can trigger painful thoughts of the rape. - rape (penetration) took place less than 72 hours ago
- the HIV status of the perpetrator is positive or unknown
- the exposed individual is not known to be HIV infected (need to offer HIV testing at time of consultation)
- defined risk of exposure, such as:
-receptive vaginal or anal intercourse without a condom or with a condom that broke or slipped; or -contact between the perpetrator's blood or ejaculation and mucous membrane or non-intact skin during the assault; or -recipient of oral sex with ejaculation; or -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 -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 for post-rape care, based on local prevalence, and ethical and resource considerations.

# Post-exposure prophylaxis (PEP) for STIs
The following recommendations were made:

# Recommendation 19
Sexual assault survivors should be offered prophylaxis/presumptive treatment for STIs including chlamydia, gonorrhoea, trichomonas and syphilis depending on prevalence. The choice of drug and regimens should follow national guidance.

# Recommendation 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 first vaccine dose.
- If immune, no further course of vaccination is required.
(a) Presumptive treatment is preferable to testing for STIs, in order to avoid unnecessary delays. Therefore, the GDG does not recommend testing prior to treatment.

# Psychological/mental health interventions (see Figure 2)
Continue to offer support and care described in recommendation 10.

# Recommendation 22
Provide written information on coping strategie for dealing with stress (with appropriate warnings about taking printed material home if an abusive partner is there).

# Recommendations 23
Psychological debriefing should not be used.
General remarks 3.5
(a) Consider the potential harms of psychotherapy (including CBT) when not administered properly to potentially vulnerable survivors. Informed consent and attention to safety is essential. A trained health-care provider with a good understanding of sexual violence should implement therapy.
(b) Pre-existing mental health conditions should be considered when making an assessment and planning care and, where necessary, treatment or referral provided as per the WHO mhGAP Intervention guide (WHO, 2010a). 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, other than her current or former partners. This may include other family members, such as a stepfather, in-law, friend of the family, or other.

# Recommendations 10 and 21
Offer first-line support to survivors of sexual assault by any perpetrator.
- 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 support.
Recommendations 11 Take a complete history, recording events to determine which interventions are appropriate, and conduct a complete physical examination, i.e. head-to-toe and including genitalia. 1
The history should include:
- time since assault and type of assault
- risk of pregnancy
- risk of HIV and other (STIs)
- mental health status.

# Recommendations 22
Provide written information on coping strategies for dealing with severe stress (with appropriate warnings about taking printed material home if an abusive partner is present).

# Figure 2. Psychological/mental health interventions
Interventions during the first 5 days after the assault:

# Recommendations 23
Psychological debriefing should not be used.

# Up to 3 months post trauma:
Continue to offer support and care described in recommendation 10
Is the person depressed? Does she have problems with alcohol or drug use or any psychotic symptoms? Is she suicidal or selfharming?
YES to one or more of these questions

# NO to all questions
Provide care in accordance with the WHO MhGAP intervention guide, 2010a
Does the person have difficulty functioning in day-to-day tasks?

# Recommendation 26
Arrange for cognitive behaviour therapy (CBT) or eye movement desensitization and reprocessing (EMDR). This should be provided by a health-care provider with a good understanding of sexual violence.

# YES Recommendation 25
Apply "watchful waiting" for one to three months after the event. Watchful waiting involves explaining to the person that she is likely to improve over time and offering the option to come back for further support by making regular follow-up appointments.

# NO Recommendation 28
Assess for mental health problems. These include symptoms of acute stress/PTSD, depression, alcohol and drug use problems, suicidality or self-harm. Treat depression, alcohol use disorder and other mental health disorders using the WHO MhGAP intervention guide, 2010a.   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 dayto-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, 2010a).

# 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, 2010a), 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. Treat injuries YES Examine and record forensic information b (refer to WHO guideline (. int/violence_injury_prevention/publications/ violence/med-leg-guidelines/en/) for guidance on consent and information).

# Training for health-care providers Recommendation 30
Training at pre-qualification level in first-line support for women who have experienced intimate partner violence and sexual assault should be given to health-care providers, in particular doctors, nurses, and midwives.

# Recommendation 33
Training for both intimate partner violence and sexual assault should be integrated in the same programme, given the overlap between the two issues and the limited resources available for training health-care providers on these issues.

# General remarks 4
(a) Priority for training should be given to those most likely to come into contact with women survivors of intimate partner violence and/or sexual assault, for example health-care providers in antenatal care, family planning or gynaecologic services, and post-abortion care, mental health and HIV, as well as primary care providers and those in emergency services.

# Health-care policy and provision Recommendation 34
Care for women experiencing intimate partner violence and sexual assault should be integrated into existing health services rather than as a stand-alone service (see Box 3 below.) Remarks a) A multicomponent programme including training of health-care providers to identify common injuries and clinical conditions commonly associated with intimate partner violence, how to provide first-line support is preferable. A clear referral pathway may also increase effectiveness. This training needs to be repeated regularly, in order to sustain the benefit (see section 2, Identification and care for survivors of intimate partner violence).
(b) Offering vertical stand-alone services may be difficult to sustain and have potentially harmful effects. For instance, there might be a risk that a currently understaffed mental health service would be further weakened if it had to provide

# Box 3
Minimum requirements for a health sector response to violence against women 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.
Monitoring and evaluation Implement a system for monitoring and evaluation, based on local policy and procedures, including considerations related to safety.
Support for the carers Provide support to those delivering care.
services specifically for victims of violence, rather than ensuring that all clients (including survivors of violence) get the best possible care.
(c) Providing support and debriefing to the carers should also be part of the healthsystems 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.

# Recommendation 35
A country needs multiple models of care for survivors of intimate partner violence and sexual assault at different levels of the health system. However, priority should be given to training and service delivery at the primary level of care.

# Recommendation 36
A health-care provider who is trained in gender-sensitive sexual assault care and examination should be available at all times of day or night at a district/area level.

# General remarks 5
(a) Until there is further evidence of the effectiveness of different models, countries need to have multiple models to provide care, but evaluation should be promoted to identify what works best and is most cost effective in different settings.
(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) Whichever 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 Recommendation 37
Mandatory reporting of intimate partner violence by the health-care provider to the police 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 as well as the risks of reporting.

# Recommendation 38
Child maltreatment and life-threatening incidents must be reported by the healthcare provider to the relevant authorities 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.
Advocacy: In the context of services for intimate partner violence, the meaning of the term "advocacy" varies within and between countries, depending on institutional settings and historical developments of the role of advocates. Broadly speaking, "advocates" engage with individual clients who are being abused, with the aim of supporting and empowering them and linking them to community services. In some health-care settings, "advocates" may also have a role in bringing about systemic change, catalysing increased recognition by clinicians of women experiencing abuse. In these guidelines, we define the core activities of advocacy as support that includes: provision of legal, Empowerment: Helping women to feel more in control of their lives and able to take decisions about their future, as articulated in Dutton's empowerment theory. Dutton notes that battered women are not "sick", rather they are in a "sick situation" and responses need to demonstrate an understanding and take into account their differing needs for support, advocacy and healing. Empowerment is a key feature of advocacy interventions and of some psychological (brief counselling) interventions. primary care centres and other service delivery points. In these guidelines, the term "health-care provider" usually refers to the primary care provider (nurse, midwife, doctor or other).
Intimate partner: A husband, cohabiting partner, boyfriend or lover, or ex-husband, ex-partner, ex-boyfriend or ex-lover.
Intimate partner violence: Behaviour by an intimate partner that causes physical, sexual or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviours. This definition covers violence by both current and former spouses and other intimate partners. Other terms used to refer to this include domestic violence, wife or spouse abuse, wife/spouse battering. Dating violence is usually used to refer to intimate relationships among young people, which may be of varying duration and intensity, and do not involve cohabiting.
Mandatory reporting: Refers to legislation passed by some countries or states that requires individuals or designated individuals such as health-care providers to report (usually to the police or legal system) any incident of actual or suspected domestic violence or intimate partner violence. In many countries, mandatory reporting applies primarily to child abuse and maltreatment of minors, but in others it has been extended to the reporting of intimate partner violence. Sexual violence: Any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed against a person's sexuality, using coercion, by any person, regardless of their relationship to the victim, in any setting, including, but not limited to, home and work.
Sexual assault: A subcategory of sexual violence, sexual assault usually includes the use of physical or other force to obtain or attempt sexual penetration. It includes rape, defined as the physically forced or otherwise coerced penetration of the vulva or anus with a penis, other body part, or object, although the legal definition of rape may vary and, in some cases, may also include oral penetration.
Routine enquiry: Sometimes used to refer to investigating intimate partner violence without resorting to the public health criteria of a complete screening programme; it can also be used to denote a low threshold for women being routinely asked about abuse in a health-care setting, but not necessarily all women.
Screening (universal screening): Large-scale assessment of whole population groups, whereby no selection of population groups is made.
Shared decision-making: When clinicians and patients make decisions together using the best available evidence. In partnership with their clinicians, patients are encouraged to consider available options and the likely benefits and harms of each, to communicate their preferences, and help select the course of action that best fits these.
Shelter: Also known as a safe house or refuge, this is usually a place, often at a secret location, where women can flee from abusive partners. Usually run by a nongovernmental organization (NGO), it was the first social and political response to partner violence from the feminist movement in high-income countries in the 1970s. However, it can also refer to a church, community group, or other setting that provides a safe haven for women.
Support: For the purposes of these guidelines, "support" includes any or a combination of the following: the provision of legal, housing and financial advice; facilitation of access to and use of community resources such as refuges or shelters; emergency housing; and psychological interventions and provision of safety planning advice.
Vicarious trauma: Defined as the transformation of the health-care provider's inner experiences as a result of empathetic and/or repeated engagement with (sexual) violence survivors and their trauma material.
Violence against women: A broad umbrella term, defined by the United Nations as "any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life". It includes many different forms of violence against women and girls, such as intimate partner violence, non-partner sexual violence, trafficking, and harmful practices such as female genital mutilation.
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