The development of Enough and Yet Not Enough: An Educational Resource Manual On Domestic Violence Advocacy For Persons With Disabilities In Washington State was led by the vision, expertise, insight, and support of the following people.

Workgroup Committee Members

Many other individuals were consulted and, although too numerous to list, their dedication to this issue and project have not gone unnoticed. A special thanks goes to all the participants at the manual review and training implementation plan meetings held on April 12 and June 18, 2001. Their critical thinking and thoughtful comments were greatly appreciated and shaped the focus of the manual and direction of the project. Particular acknowledgment is extended to Malaika Edden and Christine Olah of the Washington State Coalition Against Domestic Violence and Valerie Manucci of Abused Deaf Women's Advocacy Services.

The Washington State Coalition Against Domestic Violence gratefully acknowledges the funder that has made this project possible. This educational resource manual was supported by funding from the Washington State Department of Social and Health Services, Children's Administration, Division of Program and Policy. Points of view in this document are those of the author and do not necessarily represent the official ; position or policies of the Washington Sate Department of Social and Health Services.

This project was supported by Grant No. 2002-FW-BX0006 awarded by the Violence Against Women Office, Office of Justice Programs, U.S. Department of Justice. Points of view in this document are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Justice.

© June 2001 Washington State Coalition Against Domestic Violence. Revised 2003. All rights reserved. Permission to reproduce any portion of this report is granted, on the condition that the manual title, author, and the Washington State Coalition Against Domestic Violence, Seattle Washington, are fully credited.

There is a Rabbinic teaching from the Talmud that says: It is not incumbent upon you to complete the work, yet neither are you free to desist from it.As advocates, we are aware of how much work is left undone, yet we need to take pride in all that each of us has accomplished in our work with domestic violence survivors. This teaching reminds us that we may not finish the work, but we are expected to do all that we are capable of doing to carry it on. We don't have to do it perfectly, but survivors need all of us to keep trying.

While meeting to plan this manual, “It is enough and yet not enough” came up as a perfect example of a domestic violence advocate's feelings while trying to run a shelter for 30 battered women, and yet being unable to serve a victim in a wheelchair. Domestic violence shelters are doing enough; in the past few decades we have made great strides on many fronts to fight violence against women. We can be proud of Washington state and its excellent policies against abuse. We have served an ever-increasing number of diverse victims, and represented the issues of battered women in many governmental, business, and criminal justice system arenas. We are doing enough, it would seem, but it is not enough for people with disabilities.

It is not enough for people with disabilities because domestic violence shelters are under-serving them. Statistics repeatedly cite very high levels of abuse among persons with disabilities. If there is such a high rate of violence against persons with disabilities, why is the rate of domestic violence services to those individuals so low?

We have yet to meet the wide range of service needs presented by the estimated 10% or more of the population that has one or more disabilities, and persons with disabilities who are also victims of domestic violence are even further underserved. Disability advocates serve some victims, some are served by state caseworkers, and some are not served at all. The obstacles preventing some victims from reaching services if they are victimized often seem insurmountable.

Problems have been noted by researchers with regard to obtaining accurate incidence statistics about violence and disability. Varying definitions of abuse and reporting rates, for example, make it difficult to measure the difference in risk faced by people with and without disabilities. However, there is an accumulation of independent findings which suggests that violence is a problem of considerable magnitude for persons with disabilities.

After Linda David was “rescued” from years of abuse at the hands of her husband and caregiver, Governor Gary Locke convened a Domestic Violence Action Group to examine the circumstances surrounding Ms. David's abuse and issue recommendations regarding domestic violence intervention and prevention. In its report, published in October 1999 and entitled Everybody's Business, the Domestic Violence Action Group states:

Included in the report's recommendations are:

In response to these recommendations, the Washington State Coalition Against Domestic Violence (WSCADV), under contract with the Department of Social and Health Services (DSHS), has worked to develop this education and resource manual as a foundation for future training efforts with disability and domestic violence advocates throughout Washington state. In the course of our work, we encountered numerous challenges that will continue to require specific attention by domestic violence and disability advocates alike:

Violence against people with disabilities has been characterized as “occurring in the context of systemic discrimination against people with disabilities in which there is often an imbalance of power, including both overt and subtle forms of abuse, which may or may not be considered to be criminal acts” (The Roeher Institute, 1994). Persons with disabilities actually experience a much higher rate of abuse and have significantly fewer pathways to safety. Although people with disabilities are susceptible to the same general types of violence as the population at large, the barriers they face expose them to additional ways for perpetrators to target their abuse.

Consider the following story:

The goal of this education and resource manual is to expand the definition of what is “enough” when it comes to domestic violence advocacy, so that all domestic violence services are as accessible as possible to all persons regardless of disability.

I encourage you to read this manual and participate in the accompanying trainings that will be offered by WSCADV in the future. This manual is designed to offer practical guidelines for working with victims with disabilities. In it, we include: current issues facing victims of disability in Washington state, the laws requiring domestic violence shelters to be accessible, different types of disabilities and resources, history, experiences of victims with disabilities, tools to measure and carry out an accessibility plan, and a chapter on building allies in the disability community.

Domestic violence advocates are uniquely positioned to understand the complex suffering of people with disabilities who are victimized by violence. Our task is to take this understanding and apply it to our everyday advocacy work, to stretch the boundaries of “enough,” and to think expansively about ending all forms of violence in Washington state.

Cathy Hoog

About ten years ago, there was a planning committee for a “disability awareness day;” it was a sub-committee of a county government disability advisory committee to ensure human rights in services within that county. Attending the meeting was a strong group of advocates for persons with disabilities, most of them disabled. It was suggested that the event be called a pride day instead of an awareness day. That suggestion was quickly met with loud resistance to the use of the word “pride” in connection with persons with disabilities. In fact, one person in a wheelchair asked, “How can we be proud of something that is wrong with us?”

This attitude of internalized oppression is not unique to persons with disabilities; there are many other oppressed groups that experience it. What is concerning is that this perception of “there is something inherently and unchangeably wrong with me” is readily accepted as fact by others, and narrows our perceptions of the possibilities for self-determination in persons with disabilities.

The medical model sees a disability as a lack of something, a sad and tragic loss. Some disabled persons literally have to struggle to have an identity as a person. They are sensitive to looks, jeering, and people identifying them by their disability (e.g., “the blind guy”). A person with a disability may also be defensive if she feels that professionals are viewing her solely for the disability, rather than as a full person.

The following excerpt is from the Wall Street Journal article “Nike Rescinds Advertisement, Apologizes to Disabled People” (Grimes, 2000):

There are many possible ways to view a disability, with two extremes being:

Research has shown that disability changes the experience of the abuse. Examples of why the experience of abuse differs between women with disabilities and those without disabilities include (Myers, 1999):

The following is excerpted from The Roeher Institute (1994), Violence and People with Disabilities: A Review of the Literature, which reviewed relevant literature in Canada pertaining to violence and people with disabilities:

People with disabilities are statistically more likely to experience the following forms of abuse:

Researchers have identified a number of factors that can place people with disabilities at particular risk of abuse. In examining risk factors, several researchers have emphasized that it is not the disability itself that may put people with disabilities at risk, but the social conditions in which people with disabilities are likely to find themselves that makes it more likely that abuse will occur.

A number of studies address in some detail the risk factors associated with sexual abuse and other forms of violence affecting people with disabilities, several of which are mentioned below.

This study discusses the risk factors for violence perceived by people with disabilities. The main risk factors presented in the literature are:

It has been proven that perpetrators are very calculating and target their victims using real or perceived measures. Offenders rape very old and very young people; they are often looking for persons they perceive as without power. Some perpetrators view persons with disabilities as easy targets— persons no one will care about or persons who will be grateful for their attention. A clinician at Atascadero State Hospital reported that he overheard one sex offender tell another, “Get a job in the developmental disability system when you get out, it's easy pickings.”

The language we use to identify a group of people can shape our expectations. In the past, it was common for women to be considered weak and vulnerable; in fact, they were at much higher risks for abuse and human rights violations. Women were at higher risk not because that's the way women were, but because they did not have any individual human rights to assert. When battered women of the 1870s went to court for redress, they were turned away as having no place in the system. It was expected that they were to be abused, because they were vulnerable. In the present day, after much struggling for equal rights for women, most would be insulted to be called weak or vulnerable.

There is broad acceptance in the literature of the use of the word “vulnerable” when describing a person with a disability as being at risk of abuse. It is felt that using the word “vulnerable” to label persons with disabilities could be perceived as acceptance of the inevitable, and therefore nothing we could do would change it. The use of the word “vulnerable” assumes that persons with disabilities will be abused at a higher rate, simply because they are disabled.

Statistics do show that people with disabilities are at a higher risk of being abused, but why? Is it because they are (seen as) weak, vulnerable, or incapable of taking the steps they need to protect themselves? Are they somehow less able to protect themselves by virtue of their disability? Indeed, “vulnerability” is very difficult to measure. Perhaps it is not because they are disabled, but because they are underserved, that their risk for abuse is higher. Services for battered women and for people with disabilities have not done enough to ensure the access of all individuals to critical systems for support (e.g., emergency and criminal justice systems, domestic violence programs and disability advocacy systems).

The concept of “vulnerability” is actually victim-blaming, and is used by the abuser to maintain power and control. Abusers isolate their victims, saying it is for their own “protection and safety.” The word “vulnerable” is used to condition persons with disabilities to accept restrictive living arrangements in the name of safety. In actuality, if services designed to protect all people aren't good enough to protect persons with disabilities, then the services are inadequate. If domestic violence and disability agencies assume that victims are “vulnerable,” they might find it hard to see that their advocacy needs to improve.

Typically, domestic violence advocates and the battered women's movement think of perpetrators as intimate partners. This definition of the perpetrator needs to be broadened to include family members and paid caretakers. This rationale comes from listening to victims with disabilities and is supported by research among people with disabilities.

The Roeher Institute study (1994) identifies the following as places where violence may occur:

The research indicates that more than half of the abuse of people with disabilities is perpetrated by three groups of offenders: family members; paid care-givers; and other people with disabilities, especially those living with their victims in service settings such as residential institutions, group homes, and sheltered workshops (The Roeher Institute, 1994).

For victims with disabilities, the concept of intimacy and who participates in an intimate relationship is not limited to traditional categories of husband, spouse, partner, boyfriend, and significant other. Intimate contact by caregivers or family members gives perpetrators access and opportunity to abuse another person. Intimate contact is key to understanding when and where abuse happens regardless of who is perpetrating the abuse.

The following chart, “Comparing Levels of Intimacy,” illustrates similar abusive tactics used by intimate partners against women without disabilities and paid caretakers against women with disabilities. When making a comparison between the levels of intimacy, note that caretakers have access to many intimate aspects of the disabled person's life, and sometimes caretakers have more access to the victim than many “intimate partner” abusers. (Note: This chart is not a comprehensive list of activities or function levels; it is intended only for comparison purposes.)

Excerpted from: The Roeher Institute, 1994. Violence and People with Disabilities: A Review of the Literature. National Clearinghouse on Family Violence, Family Violence Prevention Division, Health Canada.

The study commented that people with disabilities may be reluctant to report abuse for similar reasons that non-disabled children and women do not report abuse. These reasons include fear of retaliation, dependency, and shame. Studies suggest that, for children or adults with disabilities, the difficulties of disclosing abuse are further compounded by the particular situations of living as a person with a disability. The literature suggests that people with disabilities may:

Some of the factors identified as influencing a person's decision to report or not to report abuse include:

Excerpted from: Myers, 1999. Serving Women with Disabilities: A Guide for Domestic Abuse Programs. Center for Research on Women with Disabilities, Baylor College of Medicine.

There is the possibility that, in a domestic violence situation, the victim will acquire one of many temporary (e.g., broken bones or other musculoskeletal problems) or permanent (e.g., head injury, burn injuries, spinal cord injuries) disabling conditions. When this occurs, the individual may be seen first in a hospital setting and then possibly transferred to a rehabilitation facility. Both the experience of domestic violence and the new onset of a disability need to be dealt with by the individual. The individual will be facing two life-altering events at once, and this can become overwhelming. The domestic violence agency should try to become part of the rehabilitation team to help the individual make the adjustments related to the domestic violence. The individual should be seen as someone at great risk for Post Traumatic Stress Disorder (PTSD) and dealt with accordingly. Since the individual will be experiencing essentially two losses, they may go through the stages of adjustment to a disability and/or the stages of PTSD. Both of these stage theories are similar, though the individual may progress through them at different rates. The following are examples of the two stage theories:

To effectively help the individual deal with both situations, the domestic violence agency can help her identify and contact disability resources (e.g., independent living centers, support groups) that can assist the person in her adjustment to the disability. Working as a team with agencies that can help the individual with the disability aspect of the event will make services to the individual more comprehensive and effective.

Since research has shown that victims with disabilities are often abused by a person with a disability, the inaccessibility of the criminal justice system is doubly problematic, particularly for the victim. The victim's use of the legal system can be virtually blocked by its inaccessibility.

The barriers to services can occur at many levels. Here are some anecdotal examples offered by domestic violence advocates:

Whenever possible, it is preferable to learn some basic information about the disability of the victim you are working with before you meet with her. For example, if you have information about people who are visually impaired, then have critical educational and resource materials available in multiple formats such as large print or on cassette tape. Limit your questions to the information needed in order to provide services; avoid general questions about the disability or its source (unless the information is volunteered). Remember, the reason the person is talking to you is to receive domestic violence services, not to educate you about their disability, unless it directly impacts their choices and options.

All screening and intake practices should include general accessibility questions. By routinely asking every person who requests services, the agency's ability to respond to victims with disabilities will improve. Remember, not all disabilities are visible. While most victims can explain their needs, others may not offer information beyond knowing their type of disability. Within this manual, there are sources for information on specific disability access issues and disability advocacy agencies (see Appendix for resources).

After learning about the victim's disability, try not to make any assumptions regarding the person's ability to function. During the development of the manual, many individuals wanted the information regarding types of disabilities omitted because they feared labeling and misunderstandings about a person's ability to function. We have included the descriptions of disabilities to begin educating domestic violence programs and improve accessibility for all people. Persons with disabilities have individual preferences for naming their disability, which may differ from the terminology in this manual.

Most disabilities have a continuum of capability and functioning levels; for instance, a person with visual loss may range from a mild to a severe loss of function. The victim is expert in her ability to determine her ability to function at any given time. One's functionality can change on a daily basis (e.g., a person might be stronger in the morning or hear better in one room than another).

Victims with disabilities may be sensitive to others “taking over” and understandably frustrated with unwanted help, which may be harmful. As a legally protected group of people, people with disabilities have gained rights to access in only the past ten years—rights to access the rest of us take for granted.

Be aware that persons who appear able–bodied may have a hidden disability. Ask questions that allow the person to identify their disability, to talk about their needs and necessary accommodations to participate fully in the program. Under the Americans with Disabilities Act, you cannot ask someone if they are disabled because this question is viewed as discriminatory. However, you could ask the following types of questions:

Individuals may not tell you about their disabilities immediately, but you have to let the person know that you are open to acknowledging and accommodating their needs. Building trust takes time, and it is likely that a person with a disability has overcome many barriers to connect with the domestic violence program.

The first time a victim with a disability connects with a domestic violence program sends a powerful message about the agency's understanding of accessibility. Sometimes, when a deaf victim calls a crisis line for shelter, the first question she is asked on the TTY is “Can you talk?” or “Can you write notes?” These kinds of questions make the deaf caller believe that she must be able to talk or write English in order to be accommodated. Of course, shelter staff want to know if they will be able to understand the deaf person or if they will need an interpreter. However, the staff must remember that even if the deaf victim has English skills, she will not be able to understand what staff says without an interpreter. She needs an interpreter to communicate in all educational and strategizing situations, including intake to the shelter. During the initial call, staff should ask “Do you use sign language?” or “Would you like us to call an American Sign Language interpreter?”

Unless otherwise indicated, all material in this section is adapted from: National Coalition Against Domestic Violence, 1996. Open Minds, Open Doors: Technical assistance manual assisting domestic violence service providers to become physically and attitudinally accessible to women with disabilities. Denver, CO.

A visual impairment can range in intensity from poor vision to blindness. An estimated 25% of the population has some kind of visual impairment. Only Visual about 1% of all blind people read braille; individuals who lose their sight later in life do not often learn to read braille and may rely primarily on large print materials, taped reading material, or require readers.

Things to remember when working with a victim who is blind:

Adapted from: Abused Deaf Women's Advocacy Services. 1999. Outreach and educational materials“Deafness.” Seattle, WA.

What is Deafness? Persons who cannot hear, or persons who cannot understand what they hear (with or without amplification), are deaf.

To understand deafness and its implications, it is necessary to remember that hearing persons learn a language primarily through hearing. They hear parents and siblings talk and they imitate what they hear. People who are born deaf cannot learn speech through sound, nor can they rely on it as a source of feedback. They must use other modes, such as visual, tactile, and kinesthetic senses. These senses are not as reliable for speech learning; therefore, persons who were deafened in childhood before the development of language consider English their second language, and sign language as their native language.

American Sign Language (ASL) is a language of manual gestures called signs, with its own grammatical structure and syntax. When English is introduced to a Deaf child who has grown up using ASL, English is learned as a second language. Reading and writing difficulties may be experienced because of the difference in concept and structure between ASL and English.

Deaf persons are visually oriented. They use their eyes not only to communicate in signs, but also to relate to environmental and situational stimuli. Touch and kinesthetic feedback are also important to Deaf individuals. Sound vibrations made in building structures, furniture, and cars can alert deaf person to events that hearing people identify by noise.

A common misconception is that all Deaf people can lip–read. Lip–reading, or speech reading, may help a Deaf person to understand you, but it is a skill that people possess in different degrees. Even the best lip–readers can lip–read only about 26% of all words.

Hard of Hearing. Persons who have difficulty hearing or understanding speech, but who can be assisted in hearing speech with amplification (hearing aid), are hard of hearing.

Their ability to understand speech varies, and some speakers can be understood more easily than others. Noisy surroundings may interfere with a hard of hearing person's attempts to auditorily focus on one speaker.

Make sure you get the attention of a person who is hard of hearing while you are talking. Don't cover your mouth with your hands or move around while you are speaking. Do not become frustrated by requests to repeat your conversation. If you are having difficulty with communication, writing notes may help, or if the person knows sign language, use an interpreter.

Devices. Although heard of hearing persons may be able to use the telephone with an amplification device, Deaf persons cannot use the telephone. There are telecommunication devices for the Deaf, also known as TTYs, which when coupled with a telephone receiver, allow Deaf people to communicate by typing messages and receiving printed words from a TTY at the other end.

Many Deaf persons wear hearing aids to help them identify environmental sounds, but the aids will not help a Deaf person understand speech sounds.

Some Deaf people use hearing–ear dogs to alert them to doorbell, telephone, baby cries and fire alarm sounds. These dogs have the same privileges as seeing eye dogs for the blind; they are allowed access wherever their owners may go, and must not be distracted from their duties.

Adapted from: Abused Deaf Women's Advocacy Services, 1999. Outreach and educational materials “Deaf Blindness.” Seattle, WA.

What is Deaf Blindness? Deaf blindness is a double impairment—a visual impairment severe enough to fit the legal definition of blindness, and a hearing impairment severe enough to be called deaf. It is a simple definition, but persons who are deaf–blind cannot be easily categorized when it comes to their abilities. Most deaf–blind persons are not totally deaf or totally blind. Some have usable hearing and vision.

Deaf blindness may be present from birth, or occur through an accident or later in life. The most common cause of deaf blindness is a disorder called Usher's Syndrome. In this syndrome, a person who is congenitally deaf experiences a gradual loss of vision caused by retinitis pigmentosa. In other syndromes, congenital blindness is followed by a gradual or sudden loss of hearing. Sometimes, the onset of the secondary sensory impairment does not occur until adolescence or early adulthood. This means that the person who has already adapted to one disability must learn to accept another.

Persons with Usher's Syndrome experience stages of progressive loss of vision. Generally, this disorder begins by affecting one's ability to see in the dark, a condition known as night blindness. Then gradually it affects peripheral vision, making the field of vision narrower with the progressive worsening of the disease. This is known as tunnel vision. Depending on the severity of the tunnel vision, some vision may still be usable in the very center of the visual field.

Deaf–blind people rely on many aids and devices to enhance their residual sensory abilities. Available are vibrating devices that warn the person of doorbells, alarms clocks, telephone calls, and fire alarms. There are machines that relay braille over the phone on a modified TTY machine, which is called a Tele– Braille machine. Also, many devices adapted to blind or deaf persons are used.

Communicating with someone who is Deaf, Deaf–Blind or hard of hearing:

Communicating with someone with a speech impairment:

Cognitive disabilities affect a person's ability to comprehend, remember, or discern. Many people with cognitive disabilities have received schooling or training that emphasized compliance with the wishes of authority figures. Because of this, people with cognitive disabilities may answer questions based on what they believe the questioner wants. It is important to remember to use simple and specific language and make sure the person is listening when you ask a question. Ask her to repeat what has been said or agreed, or ask the same question in different ways and notice if the responses are consistent.

Head Injuries. Head injuries can cause physical, cognitive, and psycho–social behavioral impairments. Head injuries can be caused by gunshot wounds, repeated blows to the head, a lack of oxygen reaching the brain, or sharp jerking movements. Any head injury can affect the ability of the brain to communicate with the body. The brainstem, which connects the brain to the spinal cord, contains neurons that control breathing, heartbeat, eye movements, swallowing, and facial movements. Damage to the brainstem can affect the ability of the brain to communicate with the body. Sustaining a head injury can force a person to relearn physical, cognitive, or behavioral/social skills. Some people with head injuries may need staff to present one piece of information at a time, not give complex instructions. The conversation should take place in a setting that is free of distractions, while at the same time, being careful not to patronize the person.

Communicating with someone who has a cognitive disability:

Adapted from: Abused Deaf Women's Advocacy Services, 1999. Outreach and educational materials“Learning Disabilities.” Seattle, WA.

People with learning disabilities (LD) receive inaccurate information through their senses and have trouble processing that information. Like static on the radio, the information becomes garbled as it travels from the eye, ear, or skin to the brain. The inaccurate sensory information leads to problems with reading, writing, or other vital activities such as driving. Either these skills have not been learned, have been learned after a huge effort, or have been learned poorly. Many adults with LD have trouble listening and speaking. Common problems are:

Learning disabilities are different than mental retardation. Persons with mental retardation have limited learning capacity. Persons with learning disabilities on the other hand have had specific trouble with perception or taking information in through their senses. In general, they are capable of learning and performing at their age level, but their learning is affected by the problems they have with perception. They tend to have unique ways of gathering information from the world around them.

Learning Disabilities and Attention Deficit Disorder. People who have learning disabilities process information differently and often have difficulty with writing, reading, spoken language, math, or memory. It is important to remember, however, that having a learning disability does not affect a person's overall intelligence.

Some people with learning disabilities may also have attention disorders or hyperactivity. Individuals with attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD) may be restless, easily distracted, moody, disorganized, impulsive, and have a low tolerance for stress. People with ADD/ADHD often benefit from medication and training in time management and organizational skills.

Effective communication with people who have learning disabilities or Psychiatric ADD/ADHD can be facilitated by having the person reflect back what she has heard and by limiting the amount of information presented to her at once. For people with ADD/ADHD, it is also helpful to keep steady eye contact and talk in a setting free of distractions.

Schizophrenia, Major Depressive Disorder and Bipolar Disorder are all biologically based illnesses, which have genetic backgrounds. Physical and psychological impairments can result if these illnesses are not treated. Environmental stressors do not cause mental health disorders, but they can trigger the first symptoms of mental illness.

Schizophrenia. The typical age of onset of schizophrenia is the late teens to mid–thirties. Schizophrenia can cause delusions, hallucinations and disorganized speech. A woman with schizophrenia may believe, for example, that she is being followed or that others are controlling her thoughts.

Major Depressive Disorder. Possible indicators of major depressive disorder include a loss of interest in doing things that one has found enjoyable in the past, changes in sleeping or eating patterns, fatigue. A person may exhibit feelings of worthlessness or guilt, difficulty concentrating, recurrent thoughts of death or suicide, and complaints of pains.

Bipolar Disorder. Bipolar depression includes both manic and depressive episodes. Features of a manic episode may include talkativeness, a decreased need for sleep, persistently elevated moods, racing thoughts and distractibility. A person with bipolar depression will usually alternate between manic and depressed states.

Schizophrenia, major depressive disorder and bipolar depression can all be treated with medication and therapy.

Communicating with someone who has a hidden disability or psychiatric disability:

Seizure Disorders/Epilepsy. Epilepsy is an umbrella term covering about twenty types of seizure disorders. Seizures occur when there is a brief change in the function of the electrical system of the brain. Thus, seizures are a physical disorder, not a mental disorder. Each time a person has a seizure, the flow of oxygen to the brain is limited, causing irreplaceable brain cells to die. This can affect speech, muscle coordination and vision.

Seizure disorders have no single “cause,” but can develop from a number of conditions that injure or affect the functioning of the brain such as head trauma, brain tumors, strokes, withdrawal from alcohol or other substances, poisoning, infections and developmental problems of the fetus in the womb. Seizure disorder can affect anyone, at any age, at any time.

Seizures have many forms. A person may experience massive convulsions or only a brief change in awareness, an involuntary movement, a muscle spasm, or a sensory change. For the majority of people who have epilepsy, seizures are brief and infrequent. Further, seizures can be controlled with medication. Many people with seizure disorders have not had a seizure for years and statistics show that they will probably continue to be seizure–free as long as they continue taking their medication.

To keep the airway clear during a convulsive seizure, the person only needs to be gently turned on her side.

Environmental Illness. Environmental Illness (EI) is a condition in which a person's immune system responds adversely to environmental agents, resulting in an allergic reaction. When a person's immune system hyperacts, the response is out of proportion to, and more harmful than, the initial threat of the substance. This hypersensitivity from environmental exposures may produce respiratory disorders, cognitive disorientation, skin disorders, seizures, or anaphylactic shock. This disability can be very individualized and requires working with the person to provide what is needed for them. A person with environmental illness may require the use of oxygen, the use of non–scented products, the use of air filters, or just a continuous flow of air from the outside. For severe EI, it may be necessary to have a room without carpeting or furniture made of fiberboard. Work with the woman with environmental illness to determine her needs.

Respiratory Diseases/Asthma. Chronic respiratory diseases include emphysema, allergies, asthma, chronic sinus disease, interstitial lung disease, and chronic bronchitis. Thought not all of these illnesses can be cured, many can be treated and their negative impact lessened.

Smoking most often causes emphysema, but 5% of patients who never smoke develop emphysema, indicating that a genetic defect may be the cause. Chronic bronchitis and respiratory infections are common in people who have emphysema. There is no cure for emphysema. People who have emphysema often feel continual stress because of the debilitating effects of the disease.

A narrowing and obstruction of the airways, causing problems with breathing, characterize asthma. Symptoms of asthma include coughing, wheezing, shortness of breath, and tightness in the chest. Asthma symptoms vary a great deal from person to person and from day to day.

Some asthmatics have only occasional or seasonal symptoms. Others have a more chronic form of the disease and experience symptoms daily. Some persons have “asthma attacks” when symptoms seem to develop suddenly. Attacks can be brief or last several days; prolonged attacks can be life threatening. Asthma is a chronic respiratory disease that can be controlled by medication and could be irritated by smoking, dust, fumes, allergies, infections, exercise, occupation, and stress. If a person is suffering from an asthma attack and her normal medications and treatments do not work, she should contact her doctor or a hospital.

AIDS. Increasing numbers of women are becoming infected with Acquired Immunodeficiency Syndrome (AIDS). AIDS is caused by the human immunodeficiency virus (HIV). HIV suppresses the immune system, rendering a person's body unable to fight diseases and infections, which may lead to death. People infected with the virus often look and feel healthy; the only way to determine whether one is infected is to get a blood test. There is no cure for HIV, but with education, the further progression of the virus may be slowed.

As a service provider who may interact with infected women or women who are at risk for infection, it is important to be aware of the facts about HIV/AIDS and sensitive to the needs of women who are infected with HIV/AIDS.

AIDS is spread through vaginal, anal, or oral sex with someone who is infected, or sharing a needle with someone who is infected. AIDS is not spread through handshakes, coughs or sneezes sweat or tears, food, mosquitoes, hugging, cuddling, or massage with an infected person. AIDS can be transmitted from a mother to her baby during pregnancy, childbirth, or breast–feeding. AIDS is not transmitted through swimming pools, toilet seats, phones or computers, straws, spoons, cups or drinking fountains.

For women facing the reality that they are infected with this deadly, stigmatizing virus, it is important to provide them with emotional support from support groups or therapists. It is important for staff members to remember that a woman's HIV status is a private and personal issue: it is crucial that staff members do not inadvertently “out” a woman by sharing her HIV status with other residents. Another issue to watch for is exploitation of a woman's life insurance policy: a batterer may force a woman who is HIV–positive to cash in her life insurance policy and then take her money.

Diabetes. According to the American Diabetes Association, diabetes is a disease in which the body does not produce or properly use insulin, a hormone that is needed to convert sugar, starches, and other food into the energy needed for daily life.

Over 13 million Americans have diabetes. Diabetes is incurable, but can be treated through diet, exercise, and/or insulin, depending on which type of diabetes a person has.

There are two main types of diabetes: insulin–dependent (Type I) and non– insulin dependent (Type II) diabetes. About 10% of all people with diabetes have Type I diabetes. People who have Type I diabetes generally develop diabetes in childhood or adolescence and must take insulin injections daily. Approximately 90% of people with diabetes have Type II diabetes, or non– insulin dependent diabetes. People who have Type II diabetes generally develop it after the age of 40 and must control their diet and exercise to control their diabetes. Some individuals may also need to take insulin or medication. Most people who have diabetes can learn to monitor and control their diabetes through diet, exercise, and insulin injections.

As your program becomes more attitudinally accessible and open to providing services to women with disabilities, women will become more open about talking about their disabilities and asking for specific accommodations.

Chemical Dependency. Keep in mind that not all people who drink or use drugs are alcoholics or addicts. When alcoholism or addiction is present there is great pain, shame, fear and isolation. The ADA requires you to be accessible to a recovering alcoholic, or drug addict, but does not require you to accommodate someone who is using drugs or alcohol.

Adapted from: Bland, P., 2001. Perinatal Partnership Against Domestic Violence: Train the Trainer Curriculum. Seattle, WA: Washington State Department of Health, Community & Family Health, Maternal Child Health and the Washington State Coalition Against Domestic Violence.

The development of this manual is possible because of all the efforts and struggles throughout history to obtain civil rights for women, victims' rights, and the right of access for persons with disabilities. These three struggles have many similarities, including the recognition that barriers can come in many forms and have been used to limit many different peoples. Currently, all of the groups are still struggling to obtain equal rights, and some are farther along than others.

It was only in 1990, with the passage of the Americans with Disabilities Act (ADA), that people with disabilities gained the basic right to access services that many of us take for granted. Passage of the ADA supported and strengthened organizing efforts and identification of barriers by disability advocates and persons with disabilities. Therefore, it's not surprising that the concerns of women and survivors of domestic violence are just beginning to be addressed on a systemic level.

An individual who is oppressed will have limited options for justice if the oppressed group as a whole has been deprived of human rights. For example, prisoners of war usually don't have a place to file a complaint. As Deaf persons obtained interpreters and access to information, Deaf women had the opportunity and resources to start questioning their more complicated oppressions, as did Deaf people of color, Deaf lesbians and gays, and many others.

The following timeline is a combination of multiple historic struggles from the early 1900s through 1999. It is meant to briefly highlight some important parallels.

Timeline excerpted from: Women's rights: The Path of the Women's Rights Movement— A Timeline of the Women's Rights Movement 1848–1998, http://www.legacy98.org/timeline. Copyright 1997-2001 National Women's History Project. All rights reserved. Victims' rights: Crime Victims' Rights in America: Historical Overview, Justice for Deaf Victims Training, ADWAS and Office for Victims of Crime. Compiled by the National Victim Center. Disability rights: Disability Social History Timeline, Disability Social History Project, Oakland CA, http://www.disabilityhistory.org.