Clinicians see women experiencing abuse years before a lawyer or a charity does. Very often the presentation is not an injury at all, which is why it is missed.
What to look for
- Injuries that do not match the explanation, or injuries at different stages of healing.
- Injuries to the head, neck, breasts, abdomen and arms, particularly defensive injuries to the forearms.
- Frequent attendance with vague symptoms. Headaches, abdominal pain, palpitations, insomnia with no organic cause.
- Late booking in pregnancy, missed antenatal appointments, or injury during pregnancy.
- Repeated sexually transmitted infections, or repeated requests for emergency contraception.
- A partner who answers for her, will not leave the room, or is unusually attentive in a way that prevents her speaking.
- Poor adherence to medication, which sometimes means somebody else is controlling the tablets.
- A woman who checks the time repeatedly, or who is anxious about the appointment overrunning.
Pregnancy deserves particular attention. It is one of the commonest points for violence to begin or escalate, and blows are more often directed at the abdomen then than at any other time. The detail is here.
Asking
Ask alone. This is the single most important line on this page.
Find a reason to separate them that does not sound like a reason. We need a urine sample. The scan room only takes one person. I need to check your blood pressure next door. Nobody has to invent a pretext, because clinical routine supplies one every time.
Ask directly and without euphemism. Because these symptoms are often linked to stress at home, I ask everybody. Is anyone hurting you or frightening you.
Framing it as a routine question asked of everyone removes the implication that you have concluded something about her, which is what makes women deny it.
Never use an accompanying family member as an interpreter. Ever, including children, including where she seems comfortable with it.
If she says yes
- Believe her, and say so out loud.
- Ask about immediate safety, and about children in the home.
- Treat the clinical need.
- Where relevant, offer emergency contraception and post exposure prophylaxis. Both are time critical within seventy two hours.
- Document carefully.
- Offer a referral. Do not make one without consent unless a child is at risk.
- Ask where correspondence may safely be sent, and record the answer prominently.
That last point causes real harm when it is missed. A letter or a text arriving at an unsafe address is one of the commonest ways women are exposed after seeking help.
Strangulation
Any history of pressure to the neck warrants examination the same day, regardless of external signs. Internal injury can develop over the following days with no visible mark.
It is also one of the strongest known predictors of subsequent severe violence, which means it should change your risk assessment and your urgency, not only your examination. Ask about it specifically, because women frequently do not volunteer it and often describe it as being held rather than strangled.
Documenting
Your notes may become the strongest evidence in a case that reaches court years later, and you will not be there to explain them.
- Record her words in quotation marks rather than your summary of them.
- Describe injuries by site, size and appearance. Use a body map.
- Note the time between the reported incident and the presentation.
- Photograph with consent, with a scale and the date in frame.
- Avoid words like alleges, which read as doubt in a witness statement. States is neutral and accurate.
- Note who accompanied her and whether she was seen alone.
What we tell women to ask for mirrors this, so a woman arriving with that article in mind is asking for exactly what you should already be doing.
If she says no
Accept it. Note the concern. Say the sentence that keeps the door open. If that ever changes, you can tell me, and it will not go in a letter to your house.
Many women disclose on the third or fourth asking, to the person who asked without pressing. Repeated non judgemental enquiry is the intervention with the best evidence behind it, and a denial today is not a wasted question.
Confidentiality and when you must act
Where a child is at risk of significant harm you have a duty to act. Tell her you are doing so and why, unless telling her would increase the risk to the child.
Otherwise, do not refer, report or contact anybody without her consent. Removing her control over her own situation is what is already happening to her at home.
Working with us
We can take a referral, go with a woman to an appointment, arrange counselling, and find a lawyer. Counselling and health is one of our six programmes. If you have clinical time to offer rather than a referral to make, tell us what you can do.
Questions people ask
What if I suspect but she denies it?
Document the concern, treat the presenting problem, and keep the door open. Repeated non judgemental asking is the intervention with the best evidence behind it.
When must I report without consent?
Where a child is at risk of significant harm. Tell her you are doing so and why, unless telling her increases the risk to the child.
She came with her husband and he will not leave. What do I do?
Use clinical routine to separate them. A sample, a scan, a blood pressure check next door. Never use him as an interpreter.
How should I word my notes?
Her words in quotation marks, injuries by site and size on a body map, and states rather than alleges.
If you need help now
If you are in immediate danger, call 112. To talk to HealBridge, call or send a message to +2348025170267, or use the form on our contact page. Every page on this site has a Quick Exit button at the top right, and pressing the letter E three times does the same thing.
Before you rely on anything on this page
We publish these articles so that you can understand a subject and work out what to ask for. They are written carefully and in good faith. They are still general information about how things usually work, and not advice about your situation, which we do not know.
- This is not legal advice.
- We are not a law firm. Criminal law in Nigeria is largely a state matter, the VAPP Act applies in a state only if that state adopted it, and statutory, customary and Islamic marriages are governed by different law and different courts. Two people with the same facts can have genuinely different options. Get advice from a lawyer who practises where you live — and if cost is the obstacle, ask us, because arranging that is part of what we do.
- This is not medical advice.
- Nothing here is a diagnosis and nothing here replaces being examined. Do not delay seeing a doctor, nurse or pharmacist because of something you read here, and do not start, stop or change any treatment on the strength of it. If something is time critical, go and be seen.
- This is not counselling, and it is not financial advice.
- Articles about trauma, sleep, money, debt, renting or starting a business describe what commonly helps. They are not therapy and they are not a recommendation about your own money. Speak to a counsellor, a qualified adviser or your own bank about your circumstances.
- It may be out of date, or wrong for where you are.
- Law changes, services close, numbers stop answering and practice varies by state. We correct what we find, and we cannot promise that every page is current on the day you read it. Where we do not have something confirmed, we say so rather than fill the gap.
- Reading this does not make us your lawyer or your doctor.
- No professional relationship is created by reading an article, and we cannot accept liability for decisions taken on the strength of one. What we can do is help you reach somebody who is qualified to advise you, which is what the legal and health parts of our work exist for.
- We cannot promise an outcome, and we cannot make anybody safe.
- A protection order is a piece of paper backed by an enforcement system that is inconsistent. A plan works until the day it does not. Anybody in this field promising safety is selling something, and the promise itself is dangerous because it stops people planning.
Do not let this notice stop you acting. If you are in immediate danger, call 112. If something is medically urgent, go to a hospital — you do not need a police report to be treated. And if you do not know where to start, that is a normal way to begin: use the contact page and we will take it from there.
Also worth reading:
