Thursday 20 November 2014

"Shanti's" story

"Shanti"'s * attendance to A&E was one of the moments I realised I needed to learn more about the cultural and social factors which add to the complexity of domestic violence, and eventually resulted in this WCMT travel fellowship.
(* ALL names and details have been changed to protect confidentiality)

“Shanti" attended the A&E department with police late one night. I was nurse in charge of majors, and as the police entered I felt a pang of frustration. The department was hectic as usual, phones ringing, the bustle of doctors and nurses and the stress of patients crackling in the air. The arrival of police officers is never associated with anything good. I didn't even notice Shanti at first, the police officers were tall and imposing and I deferred to them, wondering why they had come to the department. As they started to tell her story in controlled voices, I noticed her. One of the police officers held her gently but firmly by the elbow. Birdlike, her eyes flitted around the department, seemingly debating fight or flight. She was shrouded in a faded sari, the hood of which cast lunar shadows on her face. She did not make eye contact with the police or the nurses.

The police told me Shanti had been effectively kept prisoner since being brought from Bangladesh following her marriage four years previously. She had been taken out of school at age 16 even though she had wanted to continue her education, she was married in Bangladesh and brought over to the UK to live with her UK born Bangladeshi husband (her second cousin) at age 18. Now age 22, she had not seen her family for four years. She had no family or friends in London. Her husband had been violent and abusive from early on in their marriage. He didn't like her to leave the house, he treated her as if she was only useful for housework and cooking and often forced her into sex against her will. Having finished school at a young age, she spoke little English and her situation was becoming increasingly desperate. She had suffered two miscarriages previously due to physical violence from her husband whilst pregnant, and she believed she was pregnant again, yet she had no idea of the gestation as had received no ante-natal care. Shanti was terrified that harm would come to her baby and had managed to make a phone call to her uncle in Bangladesh who had alerted the police. Shanti had been brought from the house and her husband had been taken into police custody.

The story shocked me. How could a woman be living in such terror just a couple of miles from our hospital for four years?

But then I started to think... what if Shanti had attended our department during the previous four years? With an injury, or with a miscarriage. Would she have been questioned about domestic violence?

As health professionals in the emergency department we have a unique opportunity, in that we see people who might otherwise not have access to any other health services. People like Shanti, where abuse is happening 'behind the walls', and yet, whom occasionally have need of emergency medical care.

Working with a colleague, we carried out an audit to assess staff knowledge and resources for domestic violence. We found that language and cultural barriers were a main hindrance in assessment for domestic abuse. Nurses felt they did not always have time to use interpreters, and professional interpreters were not always available. Two nurses felt concerned about being culturally insensitive, in particular, if asking the husband or family to wait outside the cubicle. The majority of nurses wanted specific training on domestic abuse, which focused on how to detect it in the emergency department. None of the nurses highlighted pregnancy as a risk factor for domestic abuse. On further discussion, there was confusion among many of the nurses about 'honour' based violence and forced marriage.

This is consistent with the research and policy in this area. It suggests that people experiencing abuse will frequently attend health services and yet health care professionals often fail to ask about, or recognize domestic abuse (1). Domestic Violence London (1) cites a 1997 study in which only 6% of women attending A&E were questioned about violence, and yet approx 35% had experienced violence. When abuse is disclosed the patient may not be supported adequately (2). Furthermore, and even more worrying, are the suggestions that domestic abuse, “honour” based violence and forced marriage may be overlooked because health professionals do not wish to seem 'culturally insensitive' or they don't want to highlight their lack of understanding of certain religious or cultural practices (3). 

It was clear to me that something needed to be done to improve services in our department for victims of domestic abuse, and that health professionals require specific training on domestic abuse and how to identify it (in the emergency department), and that this training should include how to deal with the issues of “honour” based violence and forced marriage.


Since "Shanti's" attendance, we have made many changes to improve care for victims of domestic violence in our department, including the appointment of an independent domestic violence advisor who follows up referrals and carries out training in the Emergency Department. There is a much clearer referral pathway and we have increased the resources available e.g. leaflets, posters and lip balms with helpline number. However, there is a suggestion that the incidence of "honour"-based violence is increasing (4). Yet, although the need for specialist services for BME women is increasing, many are being closed down due to lack of funding (4). A 'Women's Aid' report (5) suggests that 47% of these services have had their funding cut. Some women are being advised to sleep in A&E departments or even night buses due to lack of space in refuges (6). 

As well as lobbying to ensure that provision of specialist services and refuges is preserved (you can start by signing 'womens aid' petition here: 
https://you.38degrees.org.uk/petitions/sos-save-refuges-save-lives), I feel it is necessary for those of us who work with people who may have experienced violence, to find innovative and creative ways to ensure that these patients continue to receive advice, support and a high standard of quality of care.

I found that I wanted to know more about the issues of 'honour'-based violence and forced marriage and hear from survivors themselves why these abuses occur and how we can prevent them. I want to be able to train staff in emergency departments London-wide to understand and recognize this type of abuse, and better support those who report it.  

  1. NHS (2014) Domestic Violence London: A resource for health professionals. NHS Barking and Dagenham. [Online] http://www.domesticviolencelondon.nhs.uk/ [Accessed 19/11/14] 
  2. HM Gov (2009) Domestic violence, forced marriage and “honour” based violence. The Stationary Office. Crown Copyright.[Online]
    www.womensaid.org.uk/core/core_picker/download.asp?id=1779 [Accessed 19/11/14]
  3. Kazimirski A, Keogh P, Kumari V, Smith R, Gowland S, Purdon S, Khanum N (2009) Forced marriage: Prevalence and service response. National centre for social research.
  4. Williams (2011) 'Honour' crimes against women in UK rising rapidly, figures show. The Guardian. Saturday 3rd December 2011. [Online] http://www.theguardian.com/uk/2011/dec/03/honour-crimes-uk-rising [Accessed 19/11/14]
  5. Taylor K (2013) A growing crisis of unmet need: what the figures alone don't show you. Women's Aid: Bristol. [Online] www.womensaid.org.uk/core/core_picker/download.asp?id=4245 [Accessed 20/11/14]
  6. Fawcett (2014) The triple jeopardy: the impact of service cuts on women. [Online] http://www.fawcettsociety.org.uk/2013/02/services/ [Accessed 20/11/14] 

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