Experiences of child sexual abuse clients in a Women and Children Protection Unit: policy notes
SPMC J Health Care Serv. 2019;5(1):8 ARK: http://n2t.net/ark:/76951/jhcs88p6pj
1Research Publication Office, Southern Philippines Medical Center, JP Laurel Ave, Davao City, Philippines
Correspondence Christine May Perandos-Astudillo, firstname.lastname@example.org
Received 8 March 2019
Accepted 24 July 2019
Cite as Perandos-Astudillo CM, Bolor AIJ, Concha AS. Experiences of child sexual abuse clients in a Women and Children Protection Unit: policy notes. SPMC J Health Care Serv. 2019;5(1):8. http://n2t.net/ark:/76951/jhcs88p6pj
A survey done by the World Health Organization in 2014 revealed that only less than 10% of the survivors of child sexual abuse (CSA) received any service—whether it be health, psychosocial, police, or legal.1
In Kenya and Haiti, only 13.4% of the girls and only 7% of the boys who experienced sexual abuse received health services, while in Swaziland, 24% of clients received health services.1 2 3
In several countries, one-stop centers were established to provide legal, medical and psychosocial services for survivors of child sexual abuse and violence in one location. These centers spare clients from visiting multiple institutions to seek help and from the trauma of retelling their personal ordeal to various individuals many times over.4
Psychosocial support is given by a social worker who assesses the client on the first interview. If the social worker detects any signs of abuse, the client is then escorted to an adjacent room where a child-friendly police officer would take care of the legal aspects of the case. A medical doctor performs a thorough physical examination in a separate room. Further special diagnostics and treatment are provided by the center. The staff of the centers must also have undergone appropriate training on the medicolegal aspects of handling clients who come to the center.5
In the Philippines, the establishment, operation, and maintenance of a Women and Children Protection Unit (WCPU) was based on the Administrative Order 1-B s. 1997 of the Department of Health (DOH)6
and the Republic Act 9262 Anti-Violence Against Women and their Children (VAWC) Act of 2004 and its implementing rules and regulations.7
In 2008, the DOH then developed a set of standards for the structures and processes of WCPUs in the country.8
Key results from reference brief report
The qualitative study of Parreño, et al.
in 2009 explored the experiences of 15 survivors of CSA who came to the Southern Philippines Medical Center - Women and Children Protection Unit (SPMC-WCPU). The study emphasized the importance of maintaining a positive therapeutic atmosphere provided by competent WCPU personnel, as well as the need to address certain WCPU structural and procedural issues that elicit undue discomfort among clients.9
Purpose and relevance of the policy notes
This article will explore issues surrounding health care delivery for clients in a WCPU based on the brief report of Parreño, et al. and make general recommendations accordingly.
Most of the issues that emerged in the study of Parreño, et al. may have already been addressed right after the study was conducted. The policy implications that we are presenting below can be used by any WCPU, especially those with or aiming for a Level 3 status. These may be considered by policymakers, as well as other stakeholders, before taking steps towards the improvement of WCPU services.
Policy implications of the brief report
The implementation issues from the brief report and their corresponding policy recommendations are summarized in Table 1.
1. Structural standards
Parreño, et al. study
Participants disliked that they had to see patients on their way to the WCPU office and expressed that the examination room and the comfort room of the unit do not provide adequate privacy.
Current structural standards of a WCPU
Based on the DOH performance standards, the construction or structural renovation of WCPU offices must be planned around the principles of providing convenient access to the office and a comfortable environment for the clients, maintaining the privacy of clients, and preserving the confidentiality of records. The pathway to the unit and the vital areas in the office that are commonly used by the clients—i.e. interview area, play area for children, examination room, counseling room, and comfort room—must be ideal and well-equipped to provide quality services to clients.8
The funds for the construction and maintenance of these structures can come from the Gender and Development funds, which is at least 5% of the agency’s total budget appropriations, as mandated by the government.10 11
WCPUs must have the following structural features in order to comply with the DOH standards. They must be located near the hospital emergency room. They must have two separate doors, one for entrance and one for exit, to ensure the safety and security of the clients. The reception area must be spacious to accommodate the clients and their guardians, and there must be a playroom within the premises. To maintain privacy, there must be separate rooms for interviews, counseling and medical examination. They must also have their own toilet. To ensure the confidentiality and security of records, they must have ample space for filing cabinets. They must have necessary fixtures such as an examination couch, office furniture, washing facilities, good light source and a telephone line. They must also have readily available non-traumatizing supplies and equipment for medical examination.
Parreño, et al. study
Due to the paucity of full-time service providers in the WCPU, most of the staff tended to multitask and assume various duties and responsibilities outside of the unit.
Current standards on staffing pattern, attitude, and training of personnel
As of 2018, there are 106 WCPUs and Violence Against Women and Children (VAWC) Desks located in 55 province and 10 cities across the Philippines.12
Only four WCPUs, one of which is the SPMC WCPU, were granted Level 3 (highest level) status according to Department of Health (DOH) standards. A WCPU is considered Level 3 if it is staffed with at least two physicians (an obstetrician-gynecologist and a pediatrician), at least two social workers, a registered nurse, a police officer, and a mental health professional (psychiatrist or psychologist) trained to handle any client who comes to the WCPU.813
The composition of WCPU personnel must meet the standards set by DOH in order for the unit to be self-contained and to be able to provide comprehensive services in one setting. If needed, hospitals must hire dedicated service providers to fully accommodate the number of clients that are referred daily to the WCPU. Residents-in-training must have a focused rotation at the WCPU, and they must not have other duties outside of the unit during the rotation. Although not included in the list of staff required to maintain a Level 3 WCPU, office receptionists and data encoders may also augment the daily operations of the WCPU. Office receptionists can perform various administrative duties such as answering phones, directing clients to the waiting area, etc. A data encoder is also needed in order to input WCPU clients’ information in the DOH and Child Protection Network (CPN) database registries. These additional staff can enhance the overall process flow of the WCPU, so hospitals must consider hiring them.
The WCPU staff must be well-trained and competent, and they must possess the right demeanor towards clients. They must be gender-sensitive, non-judgmental, and sincere, and they must strictly preserve the confidentiality of entrusted information. The staff must be willing to testify in court, if needed. Further, WCPU personnel must strictly adhere to the ethical guidelines in dealing with survivors of CSA, with emphasis on showing sensitivity and empathy to clients. This will ensure that clients are protected at all times against all kinds of harm. To achieve this, hospitals must provide relevant seminars that regularly train or retrain service providers on issues around VAWC, children’s rights, sexuality, bioethics, and quality of care, as well as on topics of self awareness and caring for caregivers. The WCPU staff must always work in the best interest of the survivors of CSA.
Parreño, et al. study
The clients struggled with long waiting times before any physician could attend to them and disliked having to deal with different social workers throughout the documentation process. These issues triggered unpleasant emotions in some clients and caused others some discomfort. While many clients view the overall WCPU experience as helpful and satisfying, some clients pointed out that the medical examination was physically painful and that it evoked fear, anxiety, and unpleasant memories.
Current standards on WCPU processes, ethical practices and services
Dissatisfaction with services usually happens in WCPUs when processes in the management of clients are not well-coordinated. WCPU services must be quick, responsive, efficient, and always available, and they must avoid causing further traumatic stress to clients. The DOH AO stipulates that WCPUs must be able to provide a wide array of services—including medical/surgical, psychological, social, economic, legal, and police assistance—through the utilization of the unit’s own funds and resources, and/or the implementation of referral systems.68
Further, WCPUs are required to provide their services at all times.6
However, if this is not possible, for example, due to financial constraints or to limited availability of some personnel, services may be provided on an on-call basis.15
A fully-operational referral system—which includes referral links to other government and non-government units and various professional organizations—must also be established and maintained.8
In caring for survivors of CSA, priority must be given to the survivors’ health and welfare altogether. The biopsychosocial needs of survivors must be prioritized before conducting any medicolegal procedure. Moreover, invasive physical examination, as part of medicolegal services, must be minimized. Since most of the survivors come to health care feeling humiliated and degraded, great efforts must be made to make them feel respected throughout the duration of their care.14
WCPUs must have standard protocols for conducting interviews, medical examinations, and other interventions. Standard operating procedures must be crafted in such a way that the health care and legal (police) services are immediately provided at the same time and place, with minimal number of people involved in the client’s management. This will reduce the client’s trauma in frequently retelling the distressing experiences to various service providers. Before any procedure is performed, clients must be informed about all aspects of the process, and they must express their consent or assent in writing. The WCPU must conform to the standards in providing complete and detailed information on the informed consent and assent forms, including information on preparing clients for any procedure that they are about to undergo and how the personal data of clients will be handled, especially during the course of the full medicolegal investigation of the sexual abuse.14
In compliance with the DOH AO, WCPUs must provide services all the time, 24 hours a day, 7 days a week. This way, clients do not have to wait for regular office hours to receive immediate services. If this is not feasible, clearcut policies must be made in order to ensure the presence of WCPU staff anytime their services are needed. WCPUs must also hold case conferences where all service providers are present in order to discuss the ongoing cases of clients and to plan for strategies to improve the operations of the unit.
Additionally, all WCPUs must provide their clients and their family members with comprehensive assistance—e.g., home visits, sustainable livelihood programs, educational support, parenting seminars, and psychosocial support groups.8
Implementation issues and their corresponding policy recommendations
(from the study of Parreño, et al.)
- clients had to see hospital ward patients on their way to the Women and Children Protection Unit (WCPU)
- examination room was too brightly lit, had no soundproofing, and was separated from the rest of the common room only by curtains
- comfort room in the WCPU had an opening on one wall, and the door could not be locked
WCPU location and physical arrangement
- the unit must be located near the emergency room
- clients must be able to access the unit through a direct pathway from the emergency room
- the unit must have two separate doors, one for entrance and one for exit
- reception area must be spacious
- the unit must have:
- a playroom with small tables, chairs and toys
- separate rooms for interviews, counseling, and medical examination
- its own toilet
- adequate space for filing cabinets and other equipment
- an examination couch, office furniture, washing facilities, good light source, and a telephone line
- readily available, non-traumatizing supplies and equipment for medical examination
- paucity of full-time service providers in the unit
- the unit:
- must hire dedicated service providers (at least two physicians, one nurse, at least two social workers, one police officer and one mental health professional) or ensure that they are immediately present in the unit, when the need arises
- residents-in-training must have a focused rotation at the WCPU
- may consider hiring an office receptionist to do various administrative duties and a data encoder to input clients’ information in the Department of Health and Child Protection Network database registries
Characteristics of personnel
- WCPU personnel must:
- be well-trained and competent
- show sensitivity and empathy towards clients
- be gender-sensitive, non-judgmental, and sincere
- strictly preserve the confidentiality of entrusted information
- be willing to testify in court, if needed
- WCPU personnel must undergo training on:
- issues and programs on Violence against Women and Children, children’s rights, sexuality, bioethics, and quality of care
- self awareness
- caring for caregivers
- long waiting time
- clients were handled by more than one social worker to fulfill the required documentation process
- physical examination by the physician evoked fear, anxiety, and unpleasant memories; some clients found the procedure physically painful
Delivery of services
- WCPUs must have standard protocols for:
- conducting interviews
- medical examinations
- other interventions
- WCPUs must ensure that both health care and legal (police) services are immediately provided at the same time and place
- number of personnel involved in the management of a single client must be brought to a minimum
- information in the consent and assent forms must be detailed and comprehensive
- WCPU services must be available 24/7, or clearcut policies must be made in order to ensure the presence of the staff anytime their services are needed
- WCPUs must hold periodic case conferences
- WCPUs must provide comprehensive assistance to clients and their family members
- home visits
- sustainable livelihood programs
- educational support
- parenting seminars
- psychosocial support groups
In this article, we tackled the policy implications of a brief report on the health care experience of survivors of child sexual abuse in a Women and Children Protection Unit. The policy recommendations that we made revolved around issues on physical structures, personnel, and services within the unit.
We would like to thank Dr Marie Aimee Hyacinth V Bretaña and Ms Louella S Young of the Women and Children Protection Unit in Southern Philippines Medical Center for providing the necessary information needed in this article.
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Copyright © 2019 CM Perandos-Astudillo, et al.