This summer I will be working with the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, B) in Dhaka to develop and implement a screening tool for domestic violence. Also known as intimate partner violence, the category of domestic violence refers to violence against a woman by a person with whom she is currently or was previously in an intimate relationship. Domestic violence undermines health and stifles happiness far beyond its direct injuries. Studies report that domestic violence survivors experience reduced general health—poor physical health, anxiety, depression—and more dire health outcomes for their infants and children. The impact of violence on one woman ripples through her family and her environment; it is not only a women’s health issue but a problem that disrupts entire communities.
Because this violence occurs in the private sphere of a household, its vast reach is often invisible. The 2005 World Health Organization’s “Multi-Country Study on Women’s Health and Domestic Violence Against Women” estimates prevalence rates for physical and sexual abuse between 30% and 60%. In Dhaka, where I will be working, 53.4% of all women have ever experienced physical or sexual violence by an intimate partner.
The WHO study, along with many others, calls for a greater health sector response to domestic violence. One such response is screening, a crucial gateway for identifying women who suffer from domestic violence and providing them with resources and support. A productive location for domestic violence screening is the reproductive health clinic. These clinics are already equipped to deliver sensitive and private care specifically targeted towards women; they provide a safe environment for questioning and delivery of resources.
Medical screening, however, is an insidious creature. On the surface it appears simple: develop a set of questions or tests to detect the presence of a particular condition, and produce positive or negative values for each individual. Yet the process is far more ambiguous. Not only does screening require an arbitrary line of risk to be drawn at a certain value, below which individuals are deemed safe and above which they are assigned a disease status, but it misleadingly suggests that knowledge always produces impact.
In the unique context of domestic violence in the developing world, the implications of screening are especially complex. Consider for example the global HIV/AIDS sector, where knowing one’s HIV status is deemed of utmost importance. Here, testing is the most powerful weapon in the HIV educator’s artillery, the first step towards treating the onset of the disease and preventing further transmission. However, what are the consequences of determining that a woman screens “positive” for domestic violence? There is no medication that will begin a war of attrition on this abuse; there is no material which will contain the violence and stop its spread. Additionally, palpable risks exist, especially for women in areas where privacy, mobility, and independence are limited. Women who are screened may turn to their health provider for support, yet this assistance may be inadequate or inaccessible. Women may not be able to spur any changes on their daily lives, and leave the screening experience feeling helpless or hopeless. And women may risk discovery and further violence if any healthcare intervention is discovered by abusive partners.
And yet, prominent health organizations call for routine screening of abuse because women, when surveyed, overwhelmingly want healthcare providers to question them about experiences of domestic or sexual violence. Asking about abuse is crucial and desired by individuals who experience violence, but it is ineffective if not developed thoughtfully. The work to be done lies in augmenting the act of asking from a symbolic breaking of silence to a mechanism for change. This requires implementing screening tools which are productive experiences for women and developing detailed responses and resources to intervene in “positive” screening results.
The first obstacle to effective screening involves finding the right words. The language of screening is not universal: each country, each community even, must ask sensitively about experiences of violence in a language that best reflects the respondent’s own cultural and social understandings of herself and her relationships. At the same time that screening must query in a way that predicts culturally specific notions of self and labels of behavior, it must not normalize and condone abusive behavior. By probing women about their experience after conducting a survey, my own project in Dhaka will aim to understand the rhetorical impact of the words used for screening and work to enhance the process.
Even though screening is at its core a process of detection, the sensitive nature of the domestic violence screening experience transforms it into an encounter between a patient and a healthcare provider, which is intimate, vulnerable, and full of potential for disappointment or relief. Finding this balance—of words steeped in cultural understandings which simultaneously open up the possibility of empowerment, resistance, and change—is one of the central challenges of successful screening for violence, and one which I hope to tackle through my research and reflection.
Amrapali is a rising second-year medical student at Stanford who is working with the ICDDR,B in Dhaka, Bangladesh this summer to develop screening tools for domestic violence. Her summer blog will reflect on empowerment, wellbeing, and stigma in the context of gender violence in postcolonial South Asia. She looks forward to your thoughts, comments, and questions.