It can sometimes be challenging for survivors – and their advocates – to understand which health facility to visit for different types of treatment. There are often multiple levels of health services (i.e. health posts, health clinics, mobile clinics, hospitals) with different types of staffing (e.g. nurses, doctors), equipment and facilities. So it is vital to provide clear information for first responders at community level and in other services on where to go for different health needs. At the same time, a local health post is often the only service accessible, so health staff there need to have minimum equipment and medicines, including to respond to sexual assaults. If this information is not available, you may need to conduct a mapping of existing services.

Safety in and around health facilities is vital. This can include having good lighting, female guards, and separate, lockable latrines and washing facilities. Community health workers can also support survivors to get to and from facilities. If written information on GBV is shared on site (i.e. posters, pamphlets or leaflets), these should be in private areas like washrooms which should feature appropriate warnings to survivors about taking resources home if an abusive partner is there. 

Wherever possible, services for survivors should also be integrated into existing healthcare centres in a non-stigmatising way (rather than created as stand-alone centres) so that survivors can seek care without being easily identified by the community. Health facilities should also consider the diversity of their staff. Having even one female health worker, or one representative of a minority group can help women and marginalised people access health services. Access for people with disabilities should also be guaranteed.

Many survivors will not disclose violence to a healthcare provider (or any other provider) due to fear of repercussions, social stigma, rejection from partners/families and other reasons. If healthcare providers are not well trained, they may not be able to detect the indicators of violence. Survivors may be inadvertently discouraged from asking for help for VAWG-related health problems. This can occur if the provider does not ask the right questions; if communication materials in the facility do not make clear the types of services that are available, and that they are available for all; or if the provider makes remarks or in some other way implies that the disclosure of violence will not be met with respect, sympathy and confidentiality.

Furthermore, when healthcare providers are not trained in the guiding principles of working with survivors - such as when providers do not respect patient confidentiality or understand how to address the particular needs of children - survivors may be at heightened risk of additional violence from partners, family and/or community members. Providers should be trained to establish a relationship of trust with survivors. Whilst ‘universal screening’ for violence at health check-ups is not recommended, health workers also need to have training to detect signs of violence. Then before asking about exposure to violence, the health system should have the following minimum requirements:

• Have a protocol/standard operating procedure in place
• Provide a private setting
• Ensure confidentiality 
• Have a system for referral in place
• Train health-care providers on intimate partner violence and sexual violence
• Train healthcare providers on how to ask about violence in an appropriate manner (for example, in an empathetic and non-judgmental manner) and how to respond appropriately 

The medical response and management of certain forms of violence require specialised training and knowledge by qualified healthcare providers. For example, rape survivors require specific urgent medical care that is directly related to the type of violence that they have experienced. The Clinical Management of Rape (CMR) therefore stipulates a step-by-step approach to support survivors, with contextualised approaches for children who have been raped. Healthcare providers should also be aware of how to address the health needs of survivors of child marriage (e.g., high-risk pregnancy, health effects of forced sexual activity) and complications related to female genital mutilation/cutting (e.g., pain, bleeding, urinary and vaginal infections, menstrual problems, childbirth complications, etc.).
 

Healthcare providers need to be aware of the laws and obligations on reporting sexual violence and intimate partner violence to the police or authorities. Although mandatory reporting is often intended to protect survivors (particularly children), in some cases it may conflict with the GBV Guiding Principles (see the Inter-Agency Minimum Standards for GBViE Programming, 2019). Furthermore, in the case of adults, mandatory reporting impinges on their autonomy and ability to make their own decisions. It also raises safety concerns as women may experience retaliation, fear losing custody of their children or face legal consequences (for example, in countries where extramarital sex is illegal). In countries where same-sex relationships are criminalised, people with diverse sexual orientations and gender identities may be hesitant to seek health services if mandatory reporting is required. 

Healthcare providers need to understand their legal obligations (if any) and professional codes of practice to ensure that survivors are fully informed about their choices and limitations of confidentiality where this is the case. By ensuring survivors are aware of mandatory reporting requirements, healthcare providers can help survivors make informed decisions about what to disclose during a health visit.

Asking survivors about violence needs to be linked to an effective response, which would include a first-line supportive response, appropriate medical treatment and care as needed, and referral(s) to other services. A service mapping identifying health, psychosocial, protection, legal, shelter/safe accommodation, livelihoods and other services is therefore integral for providing effective GBV support. Read more information on strengthening referral mechanisms.

All survivors of violence have a right to care and support, however, not all survivors experience violence in the same way, and some groups have multiple and intersecting vulnerabilities that can impact their health. It is important that these groups do not get overlooked in service delivery. Health services should consider what survivors need, the barriers they might face, and how to provide them with specialised services. Some examples of vulnerable groups that could need specific care include:

• Pregnant women survivors: Women and adolescent girls who experience sexual violence while pregnant may face a higher risk of complications such as miscarriage, pregnancy-induced hypertension, premature delivery and infections, including hepatitis and HIV. The health service provider should ensure that the medical drugs that are prescribed for the clinical management of rape have no side effects (or contraindications) for the pregnancy. Women and girls who are at risk of pregnancy resulting from rape should be offered emergency contraception and, as required, safe abortion services to the full extent of the law, and post-abortion care. Additionally, risks of physical, sexual or emotional intimate partner violence may increase during pregnancy and result in greater health complications.
• Adolescent girl survivors: Given their age, the risks of early pregnancy, lack of decision-making power and limited access to information and services – including health care – special attention must be given to removing barriers and facilitating their access to services. For example, parents should be informed of the potential long-term sexual and reproductive health implications of denying contraception and medical treatment to adolescent girl survivors of gender-based violence. They should also understand the life-threatening health consequences of child marriage and early pregnancy. It is important to ensure that female health service providers are available to provide counselling and treatment to adolescent girl survivors that is age-appropriate, accessible, non-judgmental and non-discriminatory. Health systems should be supported to tailor protocols for service provision to adolescent girls.
• Child survivors of sexual violence: It is important that multisectoral services including health care, psychosocial services, safety and security mechanisms, and legal assistance are available to all survivors, including children. Child survivors have specific needs regarding treatment and care that should be addressed by healthcare providers, who should be trained to identify indications of sexual violence in children, and offer care that is survivor-centred, non-stigmatising and non-discriminatory.
• Women and girls with disabilities: Persons with disabilities face particular protection risks, including a heightened risk of violence, exploitation and abuse, and high levels of stigma. Persons with disabilities are not a homogenous group, as a result, their healthcare should not be homogenous either. The attitudes and actions of GBV service providers – including healthcare actors – can be the biggest barriers or the greatest facilitators for persons with disabilities to access safe and effective services and assistance. It is important to consult persons with disabilities to identify barriers they face in accessing health services, including public health, sexual and reproductive health, maternal and child health, etc. Similarly, it’s important that healthcare staff are trained to provide disability-sensitive services and report data with disability-disaggregated information.

In situations where static, traditional GBV services are unable to reach many people due to factors like displacement, natural disasters and other emergencies like Covid-19, or remote locations, alternative options have emerged. Remote services involve staff using technology to provide GBV services from a distance, while mobile services provide services directly to people who are displaced, in transit or who cannot easily access traditional (static) services. These models can be designed according to the Leave No One Behind principle to meet the needs of GBV survivors from vulnerable, displaced, out-of-camp populations, dispersed in urban and rural settings, who are often hidden, difficult to reach, isolated, and at heightened risk of violence. Security and needs assessments should inform the design and delivery of remote and mobile response services, including reference to the minimum standards for mobile and remote GBV service delivery. Find out more about providing remote and mobile service delivery.