GCC Nurse Guide — Domestic Violence & Safeguarding

Definition of Domestic Violence

Domestic violence is a pattern of coercive control used by one person to gain or maintain power and control over another in an intimate or family relationship. It is not a single incident — it is a systematic pattern of behaviour.

Types of Abuse

Physical Hitting, slapping, kicking, strangling, using weapons
Emotional/Psychological Humiliation, threats, gaslighting, isolation
Sexual Forced intercourse, reproductive coercion, sexual humiliation
Financial Controlling money, preventing employment, debt coercion
Digital Phone monitoring, location tracking, online harassment

Classification by Relationship

Intimate Partner Violence (IPV) — current or former spouse/partner
Family Violence — parent/child, sibling, extended family
Elder Abuse — against persons 60+ years
Child Abuse — physical, emotional, sexual, neglect
Honour-Based Violence (HBV) — perpetrated in name of family honour

Prevalence

WHO Global Data
1 in 3 women worldwide (30%) experience physical or sexual violence by an intimate partner or non-partner in their lifetime. IPV accounts for the majority of violence against women.

GCC-Specific Data
Reliable statistics are limited due to significant underreporting. Estimates suggest 20–40% of Arab women experience some form of IPV. Cultural, legal, and social barriers substantially suppress reporting rates across all GCC countries.

Duluth Power & Control Wheel

The Duluth model identifies the tactics abusers use around a core of power and control:

Using Intimidation

Smashing things, destroying property, displaying weapons, threatening looks and actions

Emotional Abuse

Putting partner down, making them feel bad, humiliation, mind games

Isolation

Controlling who they see/talk to, limiting outside activities, using jealousy as justification

Minimising/Denying/Blaming

"You made me do it", denying abuse occurred, shifting responsibility

Using Children

Threats regarding custody, using children to relay messages, undermining parenting

Economic Control

Preventing employment, taking earnings, making all financial decisions

Coercive Control — Key Signs

Social isolation from friends and family
Financial control — no access to money or bank accounts
Technology monitoring — tracking apps, reading messages
Reproductive coercion — controlling contraception/pregnancy

Monitoring movements and whereabouts at all times
Controlling what victim wears, eats, or does
Degradation and humiliation, especially in public
Threats against children, pets, or family members

Cycle of Violence (Walker, 1979)

Tension Building

Stress increases, victim "walks on eggshells", minor incidents

Incident

Acute abuse episode — physical, verbal, emotional violence

Reconciliation

Apologies, gifts, promises to change, minimising behaviour

Calm/"Honeymoon"

Period of relative peace; victim hopes change is permanent

Note: The cycle may shorten over time with incidents becoming more frequent and severe. Not all relationships follow this cycle — coercive control may be continuous without "honeymoon" phases.

Presenting Patterns in Clinical Settings

History Red Flags

Frequent ED or clinic visits with vague complaints
Vague somatic complaints (headaches, pelvic pain, GI symptoms)
Delayed presentation of injuries
Injuries inconsistent with given history
Partner present at every consultation, refusing to leave
Patient looks to partner before answering questions
Partner answers all questions on patient's behalf

Physical Examination Red Flags

Bilateral injuries (as opposed to unilateral falls)
Central body injuries (trunk, chest, abdomen, genitalia)
Patterned/defensive injuries
Injuries in various stages of healing
Dental and eye injuries
Strangulation signs: petechiae over face/neck/sclera, hoarse voice, neck bruising, dysphagia
Injuries during pregnancy (abdomen, breasts)

Strangulation Alert: Strangulation is a major predictor of homicide risk. Visible injury may be absent or minimal in 50% of cases. Always ask specifically about strangulation. DASH high-risk indicator.

HITS Screening Tool

The HITS tool is a validated, brief screening instrument for domestic violence. Ask routinely in primary care and ED settings.

In the last 12 months, how often does your partner:

Hurt you physically (hit, kick, punch)?1–5

Insult or talk down to you?1–5

Threaten you with harm?1–5

Scream or curse at you?1–5

Score 4–10: Negative screen — continue routine care, document

Score ≥11: Positive screen — proceed to full assessment, safety planning, DASH risk assessment

Scale: 1=Never, 2=Rarely, 3=Sometimes, 4=Fairly often, 5=Frequently. Sherin KM et al, 1998.

WAST — Woman Abuse Screening Tool

A 2-question validated tool suitable for busy clinical environments:

Q1: "In general, how would you describe your relationship — a lot of tension, some tension, or no tension?"

Q2: "Do you and your partner work out arguments with great difficulty, some difficulty, or no difficulty?"

Positive screen: "a lot of tension" AND "great difficulty" — proceed to full DV assessment and DASH risk scoring.

DASH Risk Assessment Checklist

The Domestic Abuse, Stalking, and Honour-Based Violence (DASH) risk assessment contains 27 items. Key categories:

Category	Key Questions	Risk Weight
Lethality	Strangulation, threats to kill, victim fears being killed	Critical
Escalation	Frequency/severity increasing, weapons present or accessible	High
Children	Threats involving children, children witnessing abuse	High
Pregnancy	Pregnant or recently given birth (within 18 months)	Medium
Perpetrator factors	Substance misuse, mental health issues, jealousy/obsession	Medium
Stalking	Monitoring, following, repeated contact after separation	Medium

DASH scoring: Standard (0–2 high-risk indicators) | Medium (3–5) | High risk (6+ OR strangulation/threat to kill/fear of death)

Legal Framework Across GCC Countries

Saudi Arabia

Law on Protection from Abuse (2013) — family violence criminalised
National Family Safety Programme (NFSP) — coordinates child & family protection
Nahda Society — women's support organisation
1919 National Family Safety hotline
Victims may seek protection orders through the courts

UAE

Federal Law 28/2008 against domestic violence
Dubai Police Family Protection Unit
Dubai Foundation for Women & Children (DFWAC)
800-HOPE (4673) — national DV helpline
Protection orders available; violators face criminal penalties

Qatar

Law 22/2021 — Family Protection Law enacted
Ministry of Social Development family services
919 — social protection hotline
Qatar Foundation for Social Work involvement

Kuwait / Bahrain / Oman

Bahrain: 80008001 hotline; Family Court provisions
Kuwait: Social Affairs Ministry services; legal provisions developing
Oman: Royal Oman Police welfare units; developing legislative framework
All three countries recognise DV under general criminal codes

Cultural Factors Influencing DV in GCC

Social & Cultural Barriers to Disclosure

Family honour (sharaf/ird): Reporting abuse seen as bringing shame to the family
Wasta (influence/connections): Perpetrator's social connections may deter victims from reporting to authorities
Tribal considerations: Intra-family disputes handled within tribe; police involvement discouraged
Misinterpretation of Islamic teachings regarding marital rights (Qur'an 4:34 — scholarly debate)
Patriarchal family structures: Women expected to maintain family unit at all costs

System-Level Barriers

Kafala sponsorship system: Migrant domestic workers' residency tied to employer — extreme vulnerability
Mahram requirement: Women may need male guardian approval to access certain services
Passport confiscation: Illegal but widely practised; leaves workers unable to leave
Language barriers: Non-Arabic speaking migrants face additional obstacles
Fear of deportation: Deters undocumented workers and migrants from reporting

Clinical Pearl: A nurse who understands these barriers is better positioned to provide non-judgmental, trauma-informed care and offer appropriate culturally sensitive support without victim-blaming.

GCC DV Resources — Quick Reference

GCC DV Hotlines & Organisations ▼

Country	Hotline	Organisation
Saudi Arabia	1919	National Family Safety Programme / Nahda Society
UAE	800-HOPE (4673)	Dubai Foundation for Women & Children
Qatar	919	Ministry of Social Development
Bahrain	80008001	Ministry of Social Development
Kuwait	00965-2401-0600	Ministry of Social Affairs
Oman	24411011	Royal Oman Police Welfare Unit

The SAFE Approach to DV Disclosure

S — Safety

Always see the patient alone — no partner, family member, or child present
Use a professional interpreter — never the partner, family member, or untrained staff
Use same-gender interpreter when culturally indicated
Ensure private, confidential environment
Have a safe word/exit strategy if interrupted

A — Ask

Routine enquiry normalises the question: "We ask everyone…"
Use validated tools: HITS or WAST screening
Ask directly, without judgment: "Is anyone at home hurting you?"
Listen without interrupting; believe what you are told
Do not pressure disclosure — respect autonomy

F — Find (Document)

Document injuries objectively using a body map
Use verbatim quotes in quotation marks in the record
Photograph injuries with written, informed consent
Note size, colour, shape, location of all injuries
Maintain forensic awareness — chain of evidence

E — Evaluate

Complete DASH risk assessment
Determine safeguarding referral threshold
Assess immediate safety needs
Involve social work / safeguarding team as appropriate
Safety plan collaboratively with the patient

Documentation Principles

Documentation & Body Mapping Guide ▼

Core Documentation Principles

Use objective language — describe what you observe, not your interpretation
Record patient's words in verbatim quotation marks: e.g., "He punched me in the face"
Use correct anatomical terminology for injury location
Document: size (cm), colour, shape, edges, tenderness, stage of healing
Record date and time of documentation AND date/time injury said to have occurred
Note who was present in the consultation and what language/interpreter was used
Document refusals and patient's stated reasons

Body Map Use

Use front-and-back body diagram to mark all injury sites
Number each injury and correspond to written descriptions
Mark bruises, lacerations, burns, bite marks separately
Photograph with ruler/scale indicator and patient consent form on file
Store photographs securely in medical record system as per local policy

What NOT to Write

Avoid: "Patient claims she was hit" — use objective: "Patient states 'he hit me'"
Avoid victim-blaming language or expressions of disbelief
Avoid abbreviations that obscure clinical meaning

Mandatory vs Discretionary Reporting — GCC

Country	Child Abuse	Adult DV	Notes
Saudi Arabia	Mandatory	Discretionary	Report to NFSP; health professionals required for child cases
UAE	Mandatory	Discretionary (adult)	Child protection mandatory; DV police referral discretionary for competent adults
Qatar	Mandatory	Discretionary	Law 22/2021 allows wider referral; child protection paramount
Bahrain	Mandatory	Discretionary	Discretion guided by risk assessment

Key Principle: When a vulnerable adult lacks capacity or is at immediate risk of serious harm, mandatory reporting principles may override patient confidentiality in all GCC contexts. Always escalate when children are at risk.

Safety Planning — NNEDV Framework

Safety Planning Checklist ▼

If the victim plans to stay

Identify the safest rooms/routes in the home
Agree a code word with trusted person to signal danger
Memorise key phone numbers (support line, trusted friend)
Keep charged phone accessible at all times
Know where the nearest shelter or safe house is

If the victim plans to leave

Pack an emergency bag (documents, medications, money, clothing)
Key documents: passport, ID, residency permit, birth certificates, financial records
Contact embassy or consulate if foreign national
Contact DV hotline for safe accommodation options
Do not leave digital traces — use private browsing
Inform a trusted person of plan and timeline

Digital safety

Check phone for tracking/monitoring apps
Change passwords after leaving on a safe device
Consider getting a new SIM/phone number

Domestic Workers Under the Kafala System

Migrant domestic workers represent one of the most vulnerable groups in GCC countries. The kafala (sponsorship) system creates significant legal and practical barriers to seeking help.

Risk Factors

Residency permit tied to employer — leaving = illegal overstay
Passport confiscation (illegal but widespread)
Living within employer's home — no escape route
Language barriers and social isolation
Lack of knowledge of local laws and rights
Debt bondage from recruitment fees
Fear of deportation if they report abuse

Support Pathways for Domestic Workers

Contact home country embassy or consulate
Ministry of Labour complaint mechanisms (all GCC)
UAE: Tadbeer centres / DFWAC shelter
Qatar: Ministry of Labour migrant worker helpline
IOM (International Organisation for Migration) — repatriation support
NGO networks (limited access in GCC but present)

Nursing Action: Always ask about occupational context. If domestic worker presents with injuries, ensure interview is conducted entirely alone with a non-employer interpreter. Contact social work immediately.

Honour-Based Violence (HBV)

HBV refers to violence committed by family/community members to protect or restore perceived honour. It may involve multiple perpetrators and carries a very high risk of femicide.

Recognition Indicators

Multiple family members involved in bringing patient to hospital
Victim blaming themselves or refusing to implicate family
History of being "sent away" to country of origin
Forced marriage threats or pressure
Victim expressing fear of family (not partner)
Prior reports to police or social services involving same family

Nursing Response to HBV

Never use family members as interpreters
Never disclose patient location to family members
Treat as HIGH RISK — use DASH HBV section
Mandatory referral to safeguarding team
Specialist multi-agency response required
Do not attempt family mediation in HBV cases

Female Genital Mutilation (FGM)

WHO Classification

Type I: Clitoridectomy — partial or total removal of clitoris
Type II: Excision — partial/total removal of clitoris and labia minora
Type III (Infibulation): Narrowing of vaginal opening by cutting and repositioning labia
Type IV: All other harmful procedures — pricking, piercing, cauterising

Clinical & Safeguarding Response

Mandatory reporting for minors in all GCC contexts
Immediate safeguarding referral if child at risk
Non-judgmental, sensitive clinical approach for affected women
Obstetric complications: obstructed labour, perineal tears, PPH — anticipate in birth planning
Gynaecological complications: chronic pain, UTIs, dyspareunia, menstrual problems
Psychological support — trauma-informed care essential

Child Abuse Recognition

Types & Indicators

Physical: Unexplained bruises, patterned injuries, burns, fractures inconsistent with developmental stage
Emotional: Withdrawal, aggression, delayed emotional development, excessive compliance or defiance
Sexual: Age-inappropriate sexual knowledge/behaviour, genital injuries, STIs in children
Neglect: Poor hygiene, persistent hunger, untreated medical conditions, inappropriate clothing

Assessment Tools

Cardiff Child Protection Noticing Tool: Aids systematic recognition of physical abuse indicators
Fabricated/Induced Illness (FII): Suspect when symptoms only present when carer present, multiple investigations negative, unexplained illness in multiple siblings
Always take developmental history to contextualise injuries
Multi-disciplinary team (MDT) approach mandatory

Elder Abuse

Elder abuse affects persons aged 60+ and is significantly underdetected in healthcare settings, including across GCC countries.

EASE Tool — Elder Abuse Suspicion Index

5-question validated tool for cognitively intact older adults
Covers physical, emotional, financial abuse and neglect
Score ≥1 positive response = warranting further assessment
Administer in absence of caregiver

Red Flag Indicators

Unexplained injuries, malnutrition, dehydration
Caregiver who is hostile, domineering, or answers for the elder
Sudden changes in financial situation
Fear or withdrawal in presence of specific family member
Delayed or inconsistent presentation for medical care

GCC Hotlines — Quick Reference

GCC DV Hotlines Quick Reference ▼

Country	Number	Service	Hours
Saudi Arabia	1919	National Family Safety Programme	24/7
Saudi Arabia	011-465-5100	Nahda Society Women's Support	Business hours
UAE	800-4673 (HOPE)	Dubai Foundation for Women & Children	24/7
UAE	800-22	Abu Dhabi Social Support	24/7
Qatar	919	Ministry of Social Development	24/7
Bahrain	80008001	Ministry of Social Development	24/7
Kuwait	00965-2401-0600	Ministry of Social Affairs	Business hours
Oman	24411011	Royal Oman Police Welfare Unit	24/7
International	UNHCR hotline	Refugee DV victims — UNHCR country office	Varies

Trauma-Informed Care Principles

The 6 Key Principles (SAMHSA)

Safety — Physical and psychological safety of patient and staff
Trustworthiness & Transparency — Clear communication about processes
Peer Support — Survivor-led support mechanisms
Collaboration & Mutuality — Power-sharing in care decisions
Empowerment & Choice — Restoring sense of control
Cultural, Historical & Gender Issues — Culturally responsive practice

Clinical Application

Always ask permission before physical examination
Explain all procedures before performing them
Respect right to refuse — document refusal respectfully
Avoid clinical environments that feel threatening
Provide choices wherever possible
Recognise and validate trauma responses

Secondary Traumatic Stress in Nurses

Recognition

Intrusive thoughts/images from patient disclosures
Emotional numbing or detachment from patients
Heightened anxiety or hypervigilance
Avoidance of DV cases or related topics
Changes in world view — increased cynicism
Sleep disturbance, irritability, concentration difficulties

Mitigation & Support

Regular clinical supervision with trained supervisor
Peer debriefing after complex or distressing cases
Clear professional boundaries and self-awareness
Access to Employee Assistance Programme (EAP)
Organisational responsibility: adequate staffing, training, support
Reflective practice — maintain professional reflective diary

GCC Nursing Regulatory Competencies

DHA / DOH (UAE)

Safeguarding competencies required for all clinical nurses
Mandatory DV/safeguarding training modules in CPD
Nurses have formal duty to report and document
DOH Abu Dhabi Safeguarding Policy Framework

SCFHS (Saudi Arabia)

Saudi Commission for Health Specialties exam includes safeguarding content
Child protection and DV recognition in nursing licensure curriculum
Mandatory reporting requirements for registered nurses
National Patient Safety Taxonomy includes DV indicators

GCC Exam Practice — MCQs

Click an answer to reveal the correct response and explanation.

1. A female patient attends the ED for the third time in two months with vague abdominal pain. Her partner insists on remaining present throughout the consultation. What is the MOST appropriate initial nursing action?

A. Proceed with assessment with the partner present to maintain trust
B. Politely ask the partner to wait outside, citing hospital policy, and assess the patient alone
C. Administer pain relief and discharge with follow-up appointment
D. Contact the police immediately before speaking to the patient

Correct: B. The SAFE approach requires seeing the patient alone. A non-threatening reason (hospital policy) makes separation easier. Assessing with the suspected abuser present prevents disclosure and may increase risk. Police involvement is premature before assessment.

2. Using the HITS screening tool, a patient scores 13. What is the correct interpretation and next step?

A. Negative screen — no further action required at this time
B. Positive screen (≥11) — proceed to full DASH risk assessment and safety planning
C. Borderline result — repeat HITS in 4 weeks
D. Positive screen — mandatory police referral must be made immediately

Correct: B. HITS score ≥11 is a positive screen for domestic violence. The next step is a full DASH risk assessment and collaborative safety planning. Immediate mandatory police referral is not appropriate for competent adults in most GCC contexts — patient autonomy and safety must be considered first.

3. A nurse is caring for a migrant domestic worker in Saudi Arabia who has visible bruising on her arms and neck. She appears fearful and states she cannot leave her employer. Which factor MOST uniquely increases her vulnerability compared to a Saudi national victim?

A. Language barrier preventing disclosure
B. Lack of financial resources
C. The kafala sponsorship system tying her residency status to her employer
D. Cultural shame preventing her from speaking out

Correct: C. While all options present barriers, the kafala system is uniquely specific to migrant workers in GCC countries. It legally ties the worker's residency permit to the employer, meaning leaving constitutes an immigration violation and creates an extreme power imbalance not experienced by nationals.

4. Which physical finding is MOST associated with attempted strangulation and should prompt immediate DASH high-risk classification?

A. Bruising to both forearms in various stages of healing
B. Petechiae over the face, neck, and sclera with a hoarse voice
C. Laceration to the forehead requiring suturing
D. Bilateral periorbital bruising from blunt trauma

Correct: B. Petechial haemorrhages over the face, neck, and sclera combined with a hoarse voice are classic signs of strangulation. Strangulation is one of the most critical DASH high-risk indicators and a significant predictor of future homicide. Importantly, visible injuries may be absent in up to 50% of strangulation cases, making history-taking essential.

5. When documenting a patient's disclosure of domestic violence in the clinical record, which approach is MOST appropriate?

A. "Patient claims her husband abused her, although this could not be verified"
B. "Possible domestic violence — further investigation needed"
C. Patient states: "He punched me in the face twice last night." Bruising noted: 4x3cm purple-yellow bruise over left zygoma. Body map completed.
D. "Domestic violence suspected — social worker to review"

Correct: C. Best practice documentation uses verbatim quotes from the patient (in quotation marks), objective anatomical description of injuries with measurements, and cross-reference to a completed body map. Language like "claims" or "alleged" implies disbelief and is inappropriate. Option D lacks detail and the subjective qualifier without objective support is insufficient for forensic or legal purposes.

Domestic Violence & Safeguarding Nursing