Access provided by
London Metropolitan University
• To enhance your understanding of various forms of violence and abuse that women and girls may experience
• To enable you to recognise and provide appropriate support to women and girls who are at risk of, or experiencing, violence and abuse
• To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers)
• To contribute towards your professional development and local registration renewal requirements (non-UK readers)
Women and girls are potentially at risk of different types of violence and abuse such as sexual assault, domestic abuse, child sexual abuse, female genital mutilation and modern slavery. Nurses in primary care and community settings are well placed to identify and support women and girls at risk of, or experiencing, any such violence and abuse. It is important that nurses are aware of the risks women and girls may be exposed to, are able to recognise warning signs and know how to assess, support and safeguard patients. This article discusses common types of violence and abuse against women and girls and explains how nurses can make a difference to the lives of these women and girls through careful exploration and interventions.
Primary Health Care. doi: 10.7748/phc.2022.e1765Peer review
This article has been subject to external double-blind peer review and checked for plagiarism using automated software
Bailey RD (2022) Identifying and supporting women and girls at risk of, or experiencing, violence and abuse. Primary Health Care. doi: 10.7748/phc.2022.e1765
Published online: 06 July 2022
The aim of this article is to support nurses working in primary care and community settings to identify and support women and girls at risk of, or experiencing, violence and abuse. After reading this article and completing the time out activities you should be able to:
• Understand the definitions of terms such as sexual assault, domestic abuse, child sexual abuse, female genital mutilation (FGM) and modern slavery.
• Describe the fundamental principles of working with women and girls at risk of, or experiencing, violence and abuse.
• Outline questions that can be used to explore potential violence and abuse in female patients.
• Identify guidance and resources for assessing and supporting women and girls at risk of, or experiencing, violence and abuse.
• Forms of violence and abuse that women may experience include sexual assault, domestic abuse, child sexual abuse, female genital mutilation and modern slavery
• Nurses need to be aware of the potential risks faced by women and girls, be skilled at assessing these risks, and use every contact to attempt to identify at-risk women and girls
• It is essential for nurses to: provide an environment where people feel safe; establish a rapport and develop trust; display kindness, empathy and compassion; use attentive listening; and adopt a non-judgemental attitude
• Caring for women and girls at risk of, or experiencing, violence and abuse can be highly stressful and emotionally draining for nurses, so it is important that they acknowledge these feelings, seek support and make time for self-care
Violence and abuse against women and girls have risen globally at an alarming rate during the coronavirus disease 2019 (COVID-19) pandemic (United Nations 2020). Lockdowns, shielding, social distancing, homeworking and home schooling have all increased opportunities for perpetrators, disconnected women and girls from their support networks, and made it increasingly challenging to identify violence and abuse (Women’s Aid 2020). This article, which is based on the author’s clinical experience and on the available guidance, discusses how nurses working in primary care and community settings can assess and support women and girls at risk of, or experiencing, violence and abuse. It covers sexual assault, domestic abuse, child sexual abuse, FGM and modern slavery. The principles of nursing care described in the article are transferrable to other types of violence and abuse against women and girls, such as so-called honour-based violence.
While sexual assault, domestic abuse, child sexual abuse and modern slavery principally effect women and girls, men and boys are also at risk of, and experience, violence and abuse. Furthermore, it is important to recognise that not everyone identifies with the gender they were assigned at birth, and in this article the terminology ‘women and girls’ includes those who identify as trans, non-binary or gender fluid. There is evidence to demonstrate that trans and non-binary people have a poorer experience of healthcare (Stonewall 2015), and it is particularly important that nurses communicate sensitively with them, using the pronouns of the person’s choice to establish a therapeutic relationship so that their health needs can be assessed (Heyworth 2021).
Nurses working in primary care and community settings may be the only professionals with whom women and girls at risk of, or experiencing, violence and abuse have contact. An appointment with a nurse may be the first or the only opportunity for them to disclose abuse and may therefore be a ‘lifeline’. It is crucial that nurses are aware of the potential risks faced by women and girls, are skilled at assessing these risks, and use every contact to attempt to identify at-risk women and girls.
Nurses need to use their intuition and professional curiosity to recognise warning signs of violence and abuse. If they identify any concerns, they need to initiate a conversation about these with the woman, using considerate and respectful communication. There are many reasons why women and girls may find it challenging to discuss their experiences of violence and abuse, including fear, mistrust of authorities, not recognising themselves as victims and distress from having to revisit their trauma, so the nurse should proceed with great care and sensitivity. It is essential that the nurse provides a private, reassuring and calm environment where people feel safe. It is also important for the nurse to: establish a rapport and develop trust; display kindness, empathy and compassion; use attentive listening and non-verbal cues to encourage the person to talk; adopt a non-judgemental attitude; and validate the person’s story.
It is important that nurses find opportunities to talk to women on their own, using an independent translation service if necessary, so that a confidential conversation can take place. They need to be alert to situations where a person accompanying a woman tries to prevent her from being alone when she sees the nurse. It can be helpful to have a local policy stating that patients will be seen on their own for at least part of the consultation. If domestic abuse or modern slavery is suspected, concerns must not be raised with anyone accompanying the woman, since this could put them in greater danger.
If a woman does not disclose that she is at risk of, or is experiencing, violence and abuse, this does not necessarily mean that she is safe. She may need to develop a longer-term relationship with the nurse and be offered several opportunities to talk about her experiences before she feels able to do so. An initial enquiry by a nurse may not have an immediate effect but may ultimately lead to disclosure, possibly to someone else. If violence and abuse are suspected but not disclosed, nurses need to attempt to explore this at every further contact. Clear and accurate documentation of the episode of care and of any suspected or disclosed concerns is crucial in terms of safeguarding and potential criminal procedures.
Each situation must be approached as a potential safeguarding issue, particularly when children are involved, and safeguarding referrals must be made where necessary. Therefore, nurses need to be familiar with local and national safeguarding policies and procedures (NHS England and NHS Improvement 2019). The Royal College of Nursing (RCN) (2019a) has published an intercollegiate framework that identifies the roles of different healthcare staff in safeguarding children and young people.
The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (Nursing and Midwifery Council 2018) requires nurses to raise concerns immediately if they believe a person is vulnerable or at risk and needs additional support and protection. Such situations can create professional dilemmas and be challenging to manage, so nurses may find it useful to draw on the support and expertise of specialist nurses and safeguarding leads.
Visit the Jo’s Trust website (www.jostrust.org.uk/information/cervical-screening/cervical-screening-after-sexual-violence) and read the information on cervical screening after sexual violence. What insights did you gain? What resources do you have available to support women and girls who have experienced sexual assault?
The term ‘sexual assault’ is often used in a broad sense. For example, the sexual assaults monitored by the Crime Survey for England and Wales encompass rape (including attempts), assault by penetration (including attempts), indecent exposure and unwanted sexual touching (Office for National Statistics (ONS) 2021). However, nurses need to be aware of the legal definitions of sexual assault and other sexual offences. Box 1 shows three of the sexual offences defined in the UK by the Sexual Offences Act 2003, but there are many more.
Intentional sexual touching of another person without the person’s consent. ‘Touching’ includes touching the person with any part of the body or with anything else, touching through clothing, and touching amounting to penetration, for example kissing
Assault by penetration
Intentional sexual penetration of another person’s vagina or anus with any part of the body or with anything else without the person’s consent
Intentional penetration of another person’s vagina, anus or mouth by a penis and without the person’s consent
In England and Wales in the year ending in March 2020, an estimated 773,000 people aged between 16 years and 74 years – approximately two in 100 adults – had experienced sexual assault or attempted sexual assault as defined by the Crime Survey for England and Wales. Women were significantly more likely than men to experience sexual assault, with a prevalence rate of approximately three in 100 women and one in 100 men (ONS 2021).
Nurses may encounter women and girls affected by sexual violence in a variety of settings, for example when supporting new mothers in the community, undertaking cervical sampling in general practice, delivering care in prisons or discussing well-being in schools. Common intimate procedures, such as cervical screening tests or genital examination, can be distressing for survivors of sexual violence, so it is best practice to routinely ask women about their experience of sexual assault before an intimate procedure (RCN 2020a). This enables a holistic assessment and can provide an opportunity for women to talk about their experiences and access specialist support if required.
Women who disclose a recent sexual assault should be offered referral to the local sexual assault referral centre (SARC), whether or not they wish to report the assault to the police. At the SARC, a full assessment of their sexual health and psychological well-being will be undertaken and appropriate treatment and care provided. This will include an assessment of the risk of pregnancy, access to emergency contraception, full sexual health screening, access to hepatitis B vaccination and assessment for post-exposure prophylaxis for human immunodeficiency virus (HIV) (British Association for Sexual Health and HIV 2012). The person will be offered access to counselling and psychological support and advised of their options for reporting. Forensic samples may be taken if the person wishes to report the assault to the police.
Women who decline referral to a SARC should be offered access to their local sexual health clinic for treatment and support. Women who experience trauma from historic sexual assault should be referred to specialist services for counselling or other forms of therapy.
The Domestic Abuse Act 2021 defines domestic abuse as occurring between two people aged 16 years or over who are ‘personally connected’ – for example current or former spouses, civil partners, relatives and intimate partners – and as taking the form of physical or sexual abuse; violent or threatening behaviour; controlling or coercive behaviour; economic abuse; and/or psychological, emotional or other abuse. The majority of the provisions in the Domestic Abuse Act 2021 apply to England and Wales or England only (Home Office 2022). Scotland and Northern Ireland have similar legislation in the form of the Domestic Abuse (Scotland) Act 2018 and the Domestic Abuse and Civil Proceedings Act (Northern Ireland) 2021, respectively.
In England and Wales there is no specific criminal offence of domestic abuse, which can fall under a range of offences, including murder, manslaughter, rape, common assault, stalking, harassment and controlling or coercive behaviour. It is prosecuted as part of the Violence Against Women and Girls Strategy, which provides an overarching framework for crimes identified as being primarily committed by men against women in a context of power and control (Crown Prosecution Service (CPS) 2021b).
In the year ending March 2020, an estimated 2.3 million people aged between 16 years and 74 years experienced domestic abuse, with two thirds of them being female (Home Office 2022). Anyone can be affected by domestic abuse regardless of gender, age, sexuality, ethnicity or socio-economic background (CPS 2021b). Domestic abuse is often characterised by a pattern of behaviour that increases in frequency and severity. In some circumstances it can result in death (CPS 2021b). Abuse is not necessarily physical and can take the form of cyber-bullying or stalking.
• Do you feel safe at home? Have you ever felt unsafe in your home situation?
• Has anyone ever hit, slapped, restrained or hurt you physically or emotionally?
• At times, are you afraid of your partner, previous partner or any other significant person?
• Does your partner like to boss you around? If they don’t get their own way, how do they act?
• Have you ever been forced to do anything you are uncomfortable with?
• Have you been forced to have sex or do sexual things you are uncomfortable doing?
• When arguing with your partner, do they threaten to hurt you or the children, or someone else?
• Has your partner ever stopped you from leaving home, visiting family or friends, or going to work or school?
• Do you have a say in how to spend money?
Independent domestic violence advisers are available in many areas and can be contacted if the woman agrees. Nurses can also provide the woman with details of support services, but they need to be mindful that it is not necessarily safe for her to carry such information in writing (RCN 2020b). The safety of the woman is paramount, so nurses need to use their clinical judgement to carry out the consultation in a way that does not compromise it. If the woman appears to be in immediate danger, this must be reported to the police. Consideration must be given to children who may be affected by domestic abuse and/or be at risk of harm, and safeguarding referrals be made if required.
The move from face-to-face to telephone or online appointments has resulted in additional challenges in terms of identifying domestic abuse, since it reduces healthcare professionals’ ability to identify physical signs and non-verbal cues. SafeLives (2020) developed the ‘five Rs’, which are five simple steps that healthcare professionals can use to safely explore domestic abuse with people in virtual healthcare settings:
• Recognise and ask – ask the person whether it is safe to discuss the relationship and whether they feel safe at home.
• Respond – validate the person’s feelings.
• Risk assess – ask whether the person is in immediate danger, encourage them to phone emergency numbers such as 999 if necessary, and ask about children or vulnerable adults who may be affected.
• Refer – discuss the person with the safeguarding lead, make a safeguarding referral if appropriate, and signpost the person to local resources.
• Record – document the details of the consultation, outlining concerns and any safeguarding referrals made.
Child sexual abuse is when a child is forced or persuaded to take part in sexual activities, which may or may not involve physical contact and may occur in person or online (National Society for the Prevention of Cruelty to Children (NSPCC) (2021a). The prevalence of child sexual abuse is challenging to quantify, but it has been estimated that one in 20 children in the UK have been sexually abused (NSPCC 2021b). The key legislation relating to child sexual abuse is the Sexual Offences Act 2003 in England and Wales, the Sexual Offences (Northern Ireland) Order 2008 in Northern Ireland, and the Sexual Offences (Scotland) Act 2009 and the Protection of Children and Prevention of Sexual Offences (Scotland) Act 2005 in Scotland.
In the UK the age of consent to sexual activity is 16 years. However, mutually agreed sexual activity between under-16-year-olds of similar age is unlikely to result in prosecution unless there is evidence of abuse or exploitation (Faculty of Sexual and Reproductive Healthcare 2019). Children and young people under the age of 13 years cannot consent to sexual activity. Any sexual activity with a child under the age of 13 years is considered statutory rape and must be reported to the police and a safeguarding referral must be made (NSPCC 2021a).
Young people aged between 13 years and 16 years can consent to receive contraception, treatment of sexually transmitted infections and/or termination of pregnancy without their parents’ or carers’ knowledge or permission provided they meet the criteria set out in the Fraser guidelines (Box 3). The Fraser guidelines, which originate from legal cases, may be used by a range of healthcare professionals including doctors and nurses (NSPCC 2020). Whether or not a young person meets the criteria may change over time, so it is important that this is assessed at every contact.
To provide contraception, treatment of sexually transmitted infections and/or termination of pregnancy to a young person aged between 13 years and 16 years without their parents’ or carers’ knowledge or permission, healthcare professionals have to be satisfied that:
• The young person cannot be persuaded to inform their parents or carers that they are seeking this advice or treatment (or to allow the practitioner to inform their parents or carers)
• The young person understands the advice being given
• The young person’s physical or mental health or both are likely to suffer unless they receive the advice or treatment
• It is in the young person’s best interests to receive the advice, treatment or both without their parents’ or carers’ consent
• The young person is very likely to continue having sex with or without contraceptive treatment
Young people aged between 16 years and 18 years are assumed to have capacity to consent to sexual activity unless otherwise demonstrated. However, they are nonetheless at risk of sexual abuse or exploitation and are afforded more legal protection than adults. For example, under the Sexual Offences Act 2003, it is illegal to share sexual images of people under the age of 18 years. It is important that nurses investigate any risks or concerns regarding sexual abuse and exploitation in all young people, including those who have reached the age of consent.
If nurses encounter young people aged between 13 years and 18 years who are engaging in or planning to engage in sexual activities, they need to ensure that the sexual activity is consensual and safe. This requires the nurse to establish a rapport and adopt a conversational style to explore the circumstances of the sexual activity. It is important that the young person not only feels comfortable and trusts the nurse to respect their confidentiality, but also that they understand there are circumstances in which the nurse might have to breach their confidentiality. Therefore, the consultation should begin with an explanation of the limits of confidentiality; for example, the nurse might say:
‘This is a confidential consultation and I won’t share your information, unless you tell me something that makes me worried about your safety or the safety of others. Then I would be required to share it and put a plan in place to keep you safe. I will tell you if I need to do this. Is that okay with you?’
If there are concerns about a young person and further action is necessary, their consent is not required to share information or make a safeguarding referral, but they should be advised of any action taken and the rationale for it. The nurse might say, for example:
‘At the beginning of our meeting I said that sometimes there are situations where I have a responsibility to share your information to make sure you are safe. This is one of those situations. I am worried about what you have just told me. I am going to make a safeguarding referral and explain the situation, so that we can put together a plan to keep you safe.’
Full details of the concerns and the steps taken to safeguard the young person must be documented and the young person’s healthcare needs must be addressed.
FGM, sometimes called female circumcision or cutting, involves ‘the partial or total removal of external female genitalia or other injury to the female genital organs for non-medical reasons’ (World Health Organization (WHO) 2022). It has no health benefits and can cause immediate complications such as pain, bleeding, infection, shock and death. Long-term complications of FGM include recurrent infections, difficulty urinating and/or menstruating, difficult and/or painful sex, complications in pregnancy and childbirth, chronic incontinence and psychological issues (WHO 2022).
FGM is typically carried out on young girls between infancy and the age of 15 years. It is a traditional practice often considered a ‘rite of passage’ and associated with cultural ideals of femininity, modesty, premarital virginity and marital fidelity. Available data show that, in 30 countries where FGM is practised in Africa, the Middle East and Asia, more than 200 million women and girls have undergone FGM (WHO 2022). Macfarlane and Dorkenoo (2014) estimated that in 2011 there were 137,000 women and girls residing in England and Wales who had undergone FGM.
In the UK, FGM is illegal. In England, Wales and Northern Ireland, it is prosecuted under the Female Genital Mutilation Act 2003 as amended by the Serious Crime Act 2015, which outlines several offences relating to FGM. These include not only performing FGM in the UK, but also assisting a non-UK person to perform FGM outside the UK on a UK national or resident and failing to protect a girl under the age of 16 years from the risk of FGM (Home Office 2021, CPS 2021c).
Healthcare professionals have a duty to safeguard girls at risk of FGM and support women and girls who have undergone FGM. Nurses should be alert to FGM when they undertake general assessments, and if they have any concerns they should undertake a risk assessment using a non-judgemental and culturally sensitive approach (RCN 2019b). FGM in girls under the age of 18 years is a safeguarding issue, regardless of where it was carried out, and must be immediately reported to the police (Department of Health 2017). Practice nurses working in travel clinics are well placed to safeguard girls at risk of being taken abroad to undergo FGM. A pre-travel risk assessment should include a sensitive assessment of the risk of FGM (RCN 2020c). If a girl is in imminent danger of being taken abroad for FGM, the police must be informed and an immediate safeguarding referral must be made.
In women and girls aged 18 years or over who have undergone FGM, the focus should be on providing treatment and support. According to Bourne (2018), many survivors of FGM are never asked about its effects, which limits their access to treatment and support. Women and girls who have undergone FGM as infants may be unaware of this and the realisation can be distressing. Survivors should be asked sensitively about the effects of FGM on their physical health and mental well-being and offered access to specialist services if needed.
It is important that nurses are aware of the locally available referral pathways to specialist care and support. There are many initiatives through which health and social care professionals work with local communities on FGM awareness and education (RCN 2019b). In England there are a small number of National FGM Support Clinics providing multidisciplinary specialist care including contraception, cervical screening, deinfibulation, advocacy and psychological support (NHS England 2019). Further information and support for healthcare professionals is available through the FGM Specialist Network (www.fgmnetwork.org.uk).
The term modern slavery covers all forms of slavery, trafficking and exploitation (ONS 2020) and has been defined as the illegal trade of human beings for the purposes of commercial sexual exploitation or reproductive slavery, forced labour or a modern-day form of slavery (Department of Health 2013). Trafficking includes transporting, recruiting or harbouring a person with a view to exploit them (ONS 2020). Modern slavery can also take the form of child trafficking, forced labour, domestic servitude or debt bondage (RCN 2018). It may occur regardless of age, gender, nationality, country of residence or ethnic background. People from other parts of the world escaping poverty or conflict may be trafficked to the UK, but UK nationals or residents may also be exploited in the UK and elsewhere (ONS 2020).
Modern slavery is prosecuted under the Modern Slavery Act 2015 in England and Wales, the Human Trafficking and Exploitation (Scotland) Act 2015 in Scotland, and the Human Trafficking and Exploitation (Criminal Justice and Support for Victims) Act (Northern Ireland) 2015 in Northern Ireland. It is estimated that one in five victims of modern slavery report coming into contact with healthcare services during the time they are trafficked (RCN 2020d).
The Modern Slavery wheel (RCN 2018) details general, physical, sexual, psychological and situational signs to look out for in potential victims of modern slavery. Victims may be withdrawn or submissive, afraid to speak or accompanied by someone who appears controlling. They may give vague and inconsistent explanations about where they live and work or how an injury has occurred. They may not be registered with a GP and appear to move frequently (RCN 2021d). Additional signs in children include an unclear relationship with the accompanying adult; going missing quickly and repeatedly from school, home and/or care; giving inconsistent information about their age; and displaying an unusual attachment to those around them (RCN 2021d). Box 4 lists various health issues that can be warning signs of modern slavery.
• Old or serious unexplained and/or untreated injuries
• Recurrent and/or unexplained accidents
• Recurrent sexually transmitted infections
• Unwanted pregnancy
• Late booking in pregnancy
• Disordered eating or suboptimal nutrition
• Self-harm, including attempted suicide
• Mental, physical and sexual trauma
• Non-specific post-traumatic stress disorder
• Psychiatric and psychological signs of distress
• Dental pain and/or suboptimal dental health
• Vague symptoms such as back or stomach pain, skin conditions, headaches and dizzy spells
(Adapted from Royal College of Nursing 2018, 2021d)
Nurses who suspect that a woman or girl is being subjected to modern slavery need to raise concerns with the local safeguarding lead, document the concerns and seek immediate assistance if necessary (RCN 2018, 2021d). If it is safe to do so, patients can be signposted to support services such as the Modern Slavery and Exploitation Helpline (www.modernslaveryhelpline.org) and the Salvation Army referral helpline (www.salvationarmy.org.uk/modern-slavery/spot-signs).
Working with women and girls at risk of, or experiencing, violence and abuse can be highly stressful and emotionally draining for nurses and other healthcare professionals, who may feel overwhelmed or inadequate and can experience vicarious trauma or burnout (Maier 2011). It is crucial for nurses to acknowledge these feelings, seek support and make time for self-care. Sharing the emotional and psychological burden through clinical supervision, debriefing or reflective discussion with a colleague or mentor are often effective strategies for nurses to access support and develop their confidence and skills. Nurses may have experienced violence and abuse themselves and it is important to recognise the effects this could have on them personally and on their work. Many employers and professional organisations offer counselling and support, which are also accessible through the Cavell Nurses’ Trust (www.cavellnursestrust.org).
Nurses working in primary care and community settings will inevitably come into contact with women and girls at risk of, or experiencing, violence and abuse including sexual assault, domestic abuse, child sexual abuse, FGM and modern slavery. These issues are widespread but largely hidden and underreported, so it is crucial that nurses are able to recognise potential warning signs and ask patients appropriate exploratory questions in a safe environment. Nurses can potentially make a difference to the lives of women and girls through careful and sensitive assessment, support and safeguarding.
Consider how identifying and supporting women and girls at risk of, or experiencing, violence and abuse applies to your practice and the requirements of your regulatory body
Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account: rcni.com/reflective-account
Cavell Nurses’ Trust
FGM Specialist Network
Rape Crisis England & Wales
Salvation Army referral helpline
Health promotion in cancer care
The importance of health promotion in cancer care is...
Health promotion in palliative care
Health promotion is a discipline that, through education and...
Assessing the value of offering art activities to patients and carers
Aim The aim of this study was to determine if patients who...
Appropriate categorisation of mild pain at triage: a diagnostic study
The Manchester Triage System (MTS) offers emergency...
Severe sepsis in A&E
In this article, the author clarifies the definition of...