Global healthcare systems and violence against women and girls

Worldwide, it is estimated that approximately 30% of women have experienced violence (WHO, 2021a) and that the prevalence of violence against women and girls increases significantly once broader social inequities are taken into account such as Indigeneity, disability, race and ethnicity, 2SLGBTIQ+ status, socio-economic status and age (WHO, 2021b). Interaction with the healthcare system can provide an opportunity for a coordinated response to be enacted that provides critical care to women (Fitts et al., 2022). While there have been decades of advocacy for action to address the rates of violence against women, the breadth of minority and marginalised women’s experiences, including sexuality and gender-diverse women, in accessing healthcare following violence are only gradually becoming known (see Grand’Maison, 2024).

Globally, there are examples of significant advocacy and investment by governments, advocates and services to develop national plans to end gender-based violence for women and their children. While these national plans and frameworks are critically important, research forms part of the critical next steps to mobilise the intentions of these national plans into policy and practice. To support the work occurring across diverse national policy landscapes, the aim of this special issue was to assemble a collection of scholarly work that contributes to our understanding of minority and marginalised women’s access to healthcare following gender-based violence. The call sought to garner a collective body of scholarship that offered the potential to move our understanding of healthcare accessibility for minority and marginalised women experiencing violence forward theoretically, empirically, and practically. Each article in this special issue recognises the role the healthcare system can play in the early intervention and prevention of violence against women and girls. The collective set of papers may provide some of the necessary evidence to advance healthcare policy and strategy, programs and interventions, that identify and respond to violence against women and girls in various contexts, including programs, policy and supports that promote healing and recovery.

It is important to note that while gender-based violence is defined differently across cultures, for the purpose of this special issue, violence against women and girls is defined as intimate partner violence, domestic violence, family violence and sexual violence (see Carlson et al., 2021). The purpose of adopting this broad sociological framework was to propel potential contributors to think through the situated practices of research that afforded engaged epistemic and empirical insights in relation to the diverse nuance of health system responses at the local scale. The collection of papers thus offers a rich theoretical grounding to situate the papers’ empirical engagement with communities of minority and marginalised women and girls who experience gender-based violence and what this means for their healthcare accessibility at this critical moment. As the set of papers confers, a diverse understanding of gender-based violence facilitates critical engagements with the gendered relations of healthcare for minority and marginalised – across its continuum from policy, institutional structures, healthcare professional practice and service delivery. It illustrates those practices that occur within the local, the particular, the specific – that are locally grounded within the context of place (see Franco & Augusto, 2024; Tack & Saharso, 2024). Many of the papers capture this dynamic. While not all necessarily mention the specific politics of localised gendered practices of healthcare (see Casebolt & Hardiman, 2024; Hughes & Whitaker, 2024), a large number of the papers explore the local dynamics of gendered-healthcare delivery drawing on the rich narratives of minority and marginalised women gleaned through qualitative interviews, focus groups and creative engagements (see Rose et al., 2024 as well as Myrie & Lorde, 2024 as core examples of creative engagement in this issue).

Importantly, these rich empirical encounters also illustrate the significance of local specificity in gender-based responses to violence for women and girls from minority and marginalised women. By acknowledging that healthcare systems are not neutral systems of services, many of the papers identify the ways in which social services, systems and institutions are gendered in the care and support they provide at a time of personal crises through violence (see Fitts & Soldatic, 2024; Grand'Maison, 2024). As discussed in some level of detail, the papers map out some of the historical aspects of healthcare institutions and how this shapes accessibility for minority and marginalised women when they are in critical need of healthcare. Health systems, institutions and practices emerge from and remain embedded within local systems that govern the experience of gender-based violence, particularly for women and girls, including diverse women and girls, who live at the intersections of ‘other’ realms of severe marginalisation, exclusion and inequity. This is an overriding core theme across all of the papers. And, as a result, all papers within the collection argue that it is necessary to directly confront these ongoing historical continuities within our scholarly engaged work in the area.

In capturing these dynamics, the papers clearly are suggestive of the importance of incorporating rigorous and diverse methods to distil the gendered-intersectional structures and embodied practices that perpetuate gendered healthcare injustice at the critical moment of seeking support due to gender-based violence. The rich, creative, and diverse methods that span the papers draw out the nuanced practices of healthcare systems, institutions and delivery and the unique exclusionary and discriminatory impacts for minority and marginalised women and girls. The set of papers represents a mix of methodological techniques to capture some of the epistemic injustices within global healthcare debates that perpetuate the continued exclusion and inequities in healthcare accessibility for minority and marginalised women who consistently are denied timely, responsive, and respectful healthcare interventions when experiencing gender-based violence. Thus, recognising the affordances of diverse methodological practice to the area of research is vital to mobilise research outcomes and the impact that will generate public discussions that are transformative – both to end gender-based violence and to ensure that health systems are fully accessible and equitable in their responses to full diversity of women and girls who are experiencing gender-based violence.

Capturing this broader commitment to rigorous sociological understandings of global health systems and its implications for minority and marginalised women on a global scale, the special issue opens with an article by Casebolt and Hardiman (2024). The team draws upon national demographic and health survey data across Haiti, Pakistan, Timor Leste and Uganda to explore the prevalence of gender-based violence specifically for women and girls with disabilities who too often are excluded from global gender-based violence policy discussions as disabled women and girls are seen outside the normative frame of gender, sex and sexuality. Casebolt & Hardiman's (2024) comparative analysis across four (4) national data sets on gender-based violence found that women and girls with disabilities generally had the same or greater odds of experiencing gender-based violence and the same or lower odds of help-seeking behaviour. While the risk of experiencing violence appeared to increase with more severe disability, more research was recommended by the authors to develop a deeper understanding of this association at the local scale – that is, to move beyond broadscale national data points that national survey data affords. The authors recommended the need for programs to be developed that are accessible to all women and girls regardless of their disability and that these programs need to grapple with local nuances and disparities among women with disabilities as they do not represent a homogeneous population based upon other social markers of difference.

Using a summative content analysis, Grand’Maison (2024) examined whether and how disability and intersectionality are mobilised in public health understandings of, and strategies to address, gender-based violence. As a critical disability scholar residing in the Canadian context of Montreal, Grand Maison’s arguments in relation to gender-based violence healthcare responses to disabled women and girls, reproduce the dys-appearance of women with disabilities and power relations, namely ableism, which is historically embedded in settler colonial understandings of disability and impairment. Through utilising critical frames of analysis via the lens of critical disability studies, such as that of Paterson and Hughes (1999), Grand Maison’s work is suggestive of the long-standing arguments by disabled feminists who have mapped the ways in which healthcare services have continued to fail to provide the necessary care for women with a disability when experiencing violence, positioning them as burdens within the public health system.

The next piece navigates the different actors within the Australian healthcare system through in-depth qualitative interviews with Indigenous women, hospital staff and frontline community-based services, opening out the disjuncture across the healthcare system for Indigenous women and girls who experience family violence. The contributors, Fitts and Soldatic (2024), demonstrate how Indigenous women who present with traumatic brain injury from family violence are either excluded from seeking necessary support or, are discouraged from fully engaging in emergency healthcare and in turn, denied the necessary emergency care that is required. Drawing upon the work of Indigenous disability scholars Gilroy and Donelly (2016) and Daniels-Mayes (2023) to situate their study within settler colonial healthcare structures of racialised power in what is now known as Australia, the study explores how prolonged wait times and ongoing communication barriers reinforce Indigenous women’s positionality of marginality within the white settler healthcare system. Importantly, Fitts and Soldatic (2024) illustrate the ways in which the well-documented symptoms of traumatic brain injury, such as hyperarousal, is often misinterpreted, such as impatience and non-compliance, because of the very fact that it is Indigenous women who are exhibiting these very symptoms.

Furthering this theme of women’s racialised healthcare experiences, Hughes and Whitaker (2024) conducted interviews with women of refugee backgrounds, including from Myanmar, Ghana and Syria. As a point of comparison, the team also conducted in-depth interviews with staff from health, settlement and migration, and domestic violence support services. This comparative perspective offers readers an opportunity to understand the experiences of refugee women in relation to the strategies used by formalised service providers on which they rely to address domestic and family violence in non-metropolitan Australia. The paper, a community research project, draws upon theories of intersectionality and social-ecological models of care and support. Core stress points within the gendered-refugee resettlement process are clearly identified as key areas that need to be addressed to ensure that refugee women who experience violence can fully recover and restore their sense of self and wellbeing as new arrivals.

To highlight the subtleties of coercive control and the barriers faced by victim-survivors when attempting to access healthcare and support systems, Rose et al. (2024) use creative methods within a theatrical framework. Through the central character of ‘Kate’, a middle-class, heterosexual, white woman, the authors develop several performed vignettes that incorporate images selected by their research participants which are then projected onto backdrops. The aim of the performative approach is to first introduce, and then draw out, the commonly used tactics to establishing coercive control in new relationships that become normalised across the relationship. Importantly, through the theatrical, audiences can critically understand how these behaviours can escalate as well as interact with one another to create cycles of manipulation, fear and gaslighting. Highlighting the slowness of healthcare systems to respond to patients experiencing coercive control, Rose and colleagues (2024) recommend the need for healthcare systems to have a broader, holistic approach to the harms of violence, greater investment in initiatives that increase safety planning for women combined with education, training, screening, and referral pathways for health care professionals.

Examining the barriers that create difficulties for highly marginalised women and girls when attempting to access the Barbados health system post violence, Myrie and Lorde (2024) reflect on their deep experiences of working with a woman, ‘Zara’ and her family, as an activist and attorney-at-law, respectfully. Positioning their work on gender-based violence within the broader structures of colonial violence in Barbados and across the Caribbean, the authors draw on Black Global Feminist scholars such as Dalea Bean (2022) to situate the continuity of local colonial structures and systems and their ramifications for current access to healthcare and support services. As Myrie and Lorde (2024) highlight, any delays and exclusion from healthcare can have long-lasting impacts on the health and wellbeing for women. The authors call for multidisciplinary approaches to analysing the effectiveness of the global health system to ensure there is space for not just traditional research approaches but also methods for collecting lived expertise from women and girls from the Global South that is supported with insights from advocates and activists. The authors also suggest that national governments who are signatories to a range of global health initiatives to improve healthcare responses to gender-based violence should be required to meet a range of minimum standards as part of the ratification process including establishing and resourcing, in full, formalised, comprehensive national plans to prevent and address gender-based violence on the ground.

The following two papers in the collection explore primary healthcare responses to women experiencing violence with a particular focus on early detection. The first paper in this set by Franco and Augusto (2024) involved conducting qualitative focus groups with primary healthcare professionals in Portugal on their perceptions and practices in relation to domestic violence. Through this process, the team mapped health professionals’ perceived difficulties in the provision of timely and responsive healthcare to their client’s experiencing violence. While aware of the seriousness of violence and its lasting impacts for women, the research outlines the significant issues that emerge with a lack of specific protocols to guide frontline health professionals in the process of supporting women who have experienced violence as well as low levels of frontline health workforce knowledge and skills in gender-based violence identification. Franco and Augusto (2024) work suggests that such gaps hamper the confidence of frontline primary healthcare professionals to ask and respond adequately to the needs of women who experience violence.

Tack and Saharso (2024) and the final paper of the special issue focuses on frontline healthcare accessibility and the perceptions and knowledge of general practitioners. Through conducting qualitative interviews with general practitioners working in the Netherlands, they can interrogate general practitioners’ perceptions about the care and treatment they provide to women from non-western backgrounds who access healthcare for concerns related to violence. While patient autonomy appeared to initially be a core value of general practice, Tack and Saharso (2024) found there was variation in how general practitioners responded to the needs of women from non-western migration backgrounds who were seeking their help due to experiencing gender-based violence. Using a rights-based conception of autonomy, some general practitioners empowered women to make their own healthcare decisions, while other general practitioners decided what was ‘best’ for their patients and often actioned steps to attempt to minimise harm from the violence they were experiencing. A third and final mode was articulated by a cohort of the general practitioners interviewed who took ‘a wait and see’ approach. Tack and Saharso (2024) argue that the approach taken is dependent upon the levels of powerlessness the general practitioner and patient share about the options available to leave successfully.

To close, we feel it is important to recognise that the collection of papers all pivot around three consistent recommendations with implications for local, regional, and global healthcare systems. First, the development and implementation of gender-based violence prevention, education, assistance programs and services must be informed by the voices of women experiencing violence, who are the experts in their own communities. Such research needs to be carefully crafted to ensure that the development of research collaborations and partnerships with women who have lived through such experiences is not re-traumatising for the collaborating partners with lived expertise. This involves incorporating additional supports, being strongly aware of potential discomfort, and engagement practices that enable partners with lived expertise to extrapolate out to the generalising rather than having them drill down to their specific circumstances.

Second, comprehensive training that enables frontline health professionals across all health professions engaged in frontline healthcare is required. All the articles reveal the necessity to build, globally, workforce skills in responding the gender-based violence. However, professional healthcare skills are not only required. Given the topic of this special issue, it is clear educational and professional development needs to directly challenge racist and discriminatory attitudes, values, and normative judgements of all healthcare professionals. This is critical to ensure that minority and marginalised women have sustained contact within the healthcare system across time to enable ongoing opportunities for appropriate and responsive service support. High-quality training and education would strengthen the frontline health workforce confidence to ask their clients and patients about violence in a careful and respectful manner. It will support their development to provide responses that empower women without prevailing normative assumptions – facilitating women’s capacity to make well-informed, autonomous decisions regarding their healthcare.

Third, healthcare system responses should not operate in isolation; rather they must operate as part of broader social healthcare systems that respond as an integrated and multi-sectoral system involving justice, housing, and financial responses. This particularly includes extending systems to children to enable women to leave violent situations without fearing for children and being forced to stay in violent situations as they are only able to leave alone. All these recommendations are grounded in a greater need for future research that elevates the voices of minority and marginalised women experiencing violence. Understanding that women are not homogeneous but represent a diverse set of experiences is critical. To design, implement and deliver better systems of gendered healthcare, it is vital to recognise the intersectionality of gender with markers of difference and inequality, such as Indigeneity, race and ethnicity, disability and sexuality, so that we can understand the necessary elements of a robust and rigorous healthcare infrastructure that is respectful and responsive to all women experiencing violence.