Marion Steffens is introducing a new kind of support infrastructure for victims of domestic abuse. Her "GESINE network for health and intervention against domestic violence" responds to the lack of training among health care professionals to recognize and adequately react to signs of domestic violence. Marion's network reaches victims at the moment they visit a doctor, regardless of whether the visit directly follows an incident or not. By documenting injuries correctly, treating indirect health effects, and connecting victims to counseling and battered women shelters, Marion closes gaps in the support infrastructure for the many victims who would otherwise not seek nor find help.
The New Idea
Marion has established several organizations for battered women, and recognizes the important role doctors and health care professionals play as the first points of contact for victims. Her answer: To build long-lasting regional alliances between health care professionals and the organizations that already exist to support victims of domestic abuse. By understanding that lack of time and resources are the main obstacles to cooperation, Marion created a hands-on, replicable, step-by-step engagement strategy that allows every region to build their own network and stresses the pragmatic benefits to all stakeholders.
With the first GESINE-Network beginning in the Ennepe-Ruhr Kreis district, Marion addresses the lack of support for victims of domestic abuse in three ways: GESINE provides training and information for health care professionals on how to detect domestic violence and recognize abuse as a root cause of health conditions. It also sensitizes professionals to adequately address the problem by listening and building trust instead of judging, and finally, by creating a referral system between doctors, other health care professionals, and women’s support organizations it guarantees quality of services for victims.
Founded in 2004 GESINE is designed to be replicable in other regions. Marion developed a train-the-trainer curriculum she is implementing with other European organizations. What is more, just four years after its founding, GESINE is acknowledged as the innovative approach in the sector by being showcased as the only nationwide model project, Medical Intervention Against Violence (MIGG), working within regions and with GPs. MIGG provides funding to further develop the spread of GESINE in other regions.
There are many organizations and networks in Germany that help women affected by domestic violence, but due to stigmatization, fear or feelings of guilt only a small portion of women reach out for help. Health care professionals are not trained to detect domestic violence and diagnose it as a root cause of health conditions, nor are they properly sensitized about how to respond to the issue of domestic abuse.
According to a representative study, one in four women in Germany has experienced domestic violence; however, only a minority seeks help. The majority of victims, feeling ashamed and guilty, accept their abusive situation. Domestic violence has long lasting traumatizing effects on its victims, and can be strongly reflected in the behavior of future generations of a family. According to studies, men are eight times more likely to become offenders if they experienced domestic violence as a child, whereas women are four times more likely to be victims.
Since the start of the Frauenhaus movement (battered women shelters), there has been enormous progress in the legal status of women victims of domestic abuse. Moreover, a widespread network of support organizations has developed. But as only a fraction of victims actively reaches out for assistance, the majority does not receive support or legal reparations. Most women suffering from domestic violence visit a physician or health specialist, however, these visits fail to lead to a greater use of existing assistance. This is primarily for three reasons: First, doctors know little about the medical conditions domestic violence causes beyond the noticeable bruises and internal injuries. All sorts of psychosomatic and psychological disorders, from heart conditions to depression and excessive drinking or drug abuse can result from domestic violence. By using psychotropic drugs to treat these symptoms, unaware of the root cause, doctors weaken the woman further both emotionally and physically. Second, when confronted with domestic violence, many health professionals respond inadequately (as the majority of the population). They often tell the affected woman to leave her partner, not understanding that this is the most dangerous period for women living with a violent man and unaware of just how fearful women are of this radical change in their lives. Third, health care professionals are not trained to document injuries caused by domestic violence in a way that the reports can then be used as evidence in court. So far, most medical reports fail to meet the legal standards. This results in the fact that 85 percent of charges against acts of domestic violence are dismissed in court as compared to a 62 percent dismissal rate for non-domestic violence crimes.
Only recently has a German health care dialogue begun to discuss and study the aforementioned issues and the overall lack of support for victims of domestic abuse. It was only after the publication of the first scientific study on this topic in 2004, which for the first time brought to light the correlation between domestic violence and health problems, that players in the field began to think about including doctors to better serve victims of domestic violence. However, all efforts to engage the medical field were in vain. Neither sending educational materials to general practitioners by state governments nor training doctors (e.g. two hours of training was incorporated into curricula for gynecologists) resulted in higher diagnosis rates. While local support organizations lack the time and know-how to reach and successfully train doctors in a non-indoctrinating way.
Marion has created a systematic link between local organizations that support victims of domestic violence, using shelters and counseling services, and health care professionals. Having founded a shelter and counseling center for battered women, Marion realizes how little time and resources local organizations have to reach out to the medical community. She recognizes that medical professionals often do not realize the magnitude of the problem or how little time it actually takes from their side to dramatically improve the situation of victims. Therefore, Marion has focused her efforts on creating a model for building self-sustaining, regional networks by emphasizing the real benefits to members and empowering them to extend the network into their personal allegiances. Part of GESINE’s success is that local women support organizations are the center and organizers of the network. They have the necessary know-how to best assist women and they are already networked to other agencies and organizations. In every region in Germany there exists a “round table on domestic abuse” where social welfare offices, police, juridical and women support organizations meet, discuss, and establish best practices. These organizations are ideal to create the missing link to the health care sector, ensuring that quality standards from one side are shared with the other. To make this network tangible, GESINE created the first web-platform providing information for victims of domestic abuse, but also for health care professionals and other interested parties, including a searchable database of relevant organizations.
The main obstacle was to engage the local health care sector, as it is a conglomerate of single entities of GPs and other health care professionals that are not organized in a binding way. Marion realized that to achieve real commitment from doctors, she needed to find a practicable way of reaching them and demonstrate the tangible benefits for their day to day work. Therefore, Marion does not ask doctors to become network members out of a moral duty, but instead argues that participating in the network will help them to become more knowledgeable about how to deal with a taboo issue. It will also provide explanations for inexplicable patient behavior or symptoms, as well as connect them to a reliable referral system. The link to a network of support organizations reduces doctor’s fears that as soon as they detect domestic violence they are alone with the responsibility of intervening and helping the victim. By taking part in network trainings doctors gain Fortbildungspunkte (i.e. the amount of education credits doctors are required to achieve annually).
The development of best practices, such as conducting a market analysis of key players in each region, has allowed Marion to grow the network with little extra time and often no money, with each additional unit independently creating value for the entire network. Thus, she overcomes the most frequent argument of local organizations: Starting a regional network is not feasible due to lack of money and resources. The market analysis of the important players in a particular region’s health sector reveals who needs to be addressed to have maximum impact with little effort. With these players personal meetings are set up to sensitize them to the issue. They are then invited as experts to a multi-professional conference on the topic of domestic abuse, and from the very beginning they have to take an active role as speakers or panelists. This process helps them take ownership and understand the importance of the network to their work. Next, they are invited to become founding members of the regional network and act as active multipliers in their field or profession.
The network is based upon a set of expectations that members must abide by: Signaling openness to the topic (i.e. by posting posters in their waiting room and flyers on the lady’s rest room); noticing and addressing the topic of violence (i.e. removing all taboos); and responding adequately (i.e. without judgment; but informing and referring victims to relevant support organizations).
Besides organizing regional conferences, the network provides comprehensive trainings (mandatory for members on an annual basis). GESINE also provides information and documentation templates on how to legally document injuries caused by domestic violence. This ensures the quality of the referral system inside the network—guaranteeing women receive appropriate help as quickly as possible. As Marion knows how often women are sent from one organization and state support program to the next, until someone provides adequate support, this quality safeguard is of fundamental importance. She and her team are in regular contact with victims; they receive direct and constant feedback on the quality of network organizations as well as suggestions for improvement—a key success factor for the project and its acceptance. Another important aspect is that the network members come from all sorts of medical professions, including physiotherapists or psychologists; mirroring the range of medical conditions caused by domestic violence.
The first GESINE-Network in the Ennepe Ruhr Kreis (i.e. a rural, administrative district in the west of Germany) has 80 network members, both institutional and personal, to serve several thousand women a year. Additionally, this first GESINE-Network reaches approximately 200 additional professionals in the health care sector a year through conferences and informative meetings. Through regular round tables, it is also in contact with about 80 other organizations (police, justice, and so on). Whereas before the founding of the network, no doctor ever referred a woman suffering from domestic violence to Frauen helfen Frauen, the primary support association in the region. Now 20 percent of all institutional referrals come from doctors. There is further outreach through PR campaigns—such as messages on posters in buses (Without violence women are traveling safer) or print ads on bakery product paper bags (Gewalt kommt nicht in die Tüte – a wordplay meaning “Violence is out of the question” but is literally translated as “Violence does not go in a bag”). Through her train-the-trainer concept, Marion has regionally trained several women’s organizations, resulting in the founding of a network in the north of Germany and a third network in Hessen. This spread is financed by training fees. In order to systematize this spread and ensure quality control, Marion is thinking about the pros and cons of a social franchise strategy.
Nationally, Marion is a renowned expert in the field of fighting domestic violence in Germany and a member of all relevant national committees around this topic. Through this, Marion is presenting GESINE and what they have learned at important multiplier meetings and conferences all over Germany. GESINE has succeeded in becoming a national model project for medical intervention against domestic violence funded by the German government. This recognition has given nationwide attention to Marion and her work. It also equips her with the necessary funding to improve her training material and provides her with scientific evaluation, which allows her to reach more regions.
On the European level, Marion has been involved in a European Union program on “Improving multi-professional and health care training in Europe—building on good practice in violence prevention (2007 to 2009).” As part of an expert team to develop specific training modules for health care professionals, Marion has spread parts of her approach to existing community level networks in seven European Union countries. Currently Marion is expert partner of a further EU Program on “capacity-building on female prisoners with a history of violence and abuse.” As the German study on “Health, well-being and personal safety of women in Germany points out the prevalence rates for violations in female prisoner population are extremely high. Therefore the overall goal of the program is to build capacity for criminal justice professionals and develop a toolkit for other relevant professionals such as advocates, social workers and so on.
Born into a male dominated family, Marion considers herself a feminist from birth. From early childhood she began to protest against gender stereotypes, but never felt defensive and never ceased to see the humorous aspects of these discussions. Another important and much more serious topic for her was her reflection on the Nazi system and how so many German’s actively agreed with its inhumane beliefs. The more she was engaged in the topic, the more she believed that one needs to reject ideological answers to difficult political questions.
Marion studied social pedagogy and started to work in the health care sector in a home for the elderly. In the 1980s Marion was already helping to introduce the topic of violence into the biography work of elderly people, having tangible positive results. In the beginning of the 1990s, in the face of heavy resistance, she founded a Frauenhaus in the Ennepe Ruhr Region. The male dominated communal council denied the existence of violence against women. Her non-ideological method of presenting the facts and explaining the financial costs of ignoring the problem enabled her succeed in the end. To reach more women she added a counseling center a couple of years later.
On the heavily ideological topic of domestic violence, she constantly found ways to overcome conflicts and to create a matter-oriented debate. Her key insight: The more responsibility people undertake, the less likely they are to stick to ideologies, but instead will automatically find pragmatic ways to solve the problem. Marion is a member of all relevant domestic abuse networks, fighting for a more sensitive, low threshold, and empowering approach to help to overcome inadequate and discriminating laws as well as the countrywide taboo and stigma that surround the topic.
When she discovered just how important doctors are for obtaining legal evidence, and she saw the dramatic health effects that domestic violence has on women, she tirelessly began to work for an approach which would allow her—and other people working in the field—to reach out to victims while continuing their day-to-day work. In addition to setting up GESINE, she has begun to pragmatically work on many other aspects of the problem, including developing anti-violence trainings for offenders.