Gender Violence:The Health Impact – Getting Gender Violence on the Public Health Agenda

by Anupama Srinivasan

The impact of gender violence – and specifically violence against women – extends beyond what a girl or woman endures today, tomorrow or three months from now. Gender violence affects an individual’s ability to go to school, to enter into a relationship with someone of her/his choice, to go out to work, to earn an income, to use public transport and to be financially independent. The threat of violence means that a girl may be withdrawn from school by her parents; that women may lead lives of fear, placing constraints upon their own mobility and that of other girls and women in the family. Most of all, gender violence denies an individual the right to lead a healthy life, free of injury, illness and disease.

In this journey from violence and trauma to (hopefully) healing, healthcare providers – doctors, nurses, hospital administrators, community volunteers – are what the NGO world likes to call ‘key stakeholders’. There is considerable evidence to show that healthcare providers can play a crucial role in responding to gender violence, not just in the provision of health services but also in collecting data on prevalence, risk factors and health consequences; in informing polices to address GBV and in preventing violence[1].

But the fact is, in India, few hospitals (whether in the public or private sector) have in place a comprehensive response system that helps them to identify and support women who have experienced gender and sexual violence. This is despite the fact that globally, gender violence is recognised as a legitimate public health issue, with both immediate and long-term consequences for the health and well-being of women. Violence can potentially impact a woman’s physical, mental, sexual, reproductive and maternal health and ironically, also restrict her access to health care.

Impact of violence on health

VAW Health Impact

Source:  http://www.who.int/reproductivehealth/publications/violence/VAW_health_impact.jpeg?ua=1

Rape, domestic violence and intimate partner violence are particularly insidious for women’s health. For those who face abuse at home regularly, severe abrasions, bruises, broken and dislocated bones as well as burn injuries are not uncommon. Rape can and often does result in unwanted pregnancies, which in turn can lead to unsafe abortions as well as, potentially, subsequent infertility.

Women who are raped are vulnerable to HIV and AIDS. Equally common, but far less publicly discussed are sexually transmitted infections, urinary tract infections, genital injuries and pelvic inflammatory disease. Women are often too ashamed or embarrassed to seek help for any pain or injury related to the ‘private’ parts of their bodies; as a result, these infections can remain both undiagnosed and untreated. In addition, women who have been raped (whether by strangers or partners) can develop an aversion to sex, which they are often reluctant to disclose to anyone, including and especially their husbands. This can, in turn, become triggers for a cycle of violence including marital rape and intimate partner violence.

The long-term impact of gender violence is far more nebulous. Recurring anxiety, increased use of alcohol or other forms of substance abuse, eating disorders, frequent menstrual pain, chronic headaches, fatigue, disturbed sleeping patterns, depression and post-traumatic stress disorder or PTSD are all potential mental health consequences of gender violence. Given the dual stigma associated with both mental illness and sexual violence, women are even less likely to seek medical or psychological support, with distressing long-term results.

Forced and early marriages of both boys and girls also result in several health complications that go unacknowledged by families. Young girls, if married before the age of 18, have little knowledge about sex, the threat of STIs or HIV and AIDS. They also have little negotiating power for contraception use. Inevitably, the earlier a girl is married, the younger she is when she gives birth to her first child. And the more likely she is to have more than her fair share of children, with a multitude of long-term consequences for her own health.

Health sector response to gender violence

Over the last few years, I’ve been part of several training programmes for students at different nursing colleges. The objective of these programmes was to help these young women, mostly between the ages of 17 and 25, understand the role they could play as nurses. After all, nurses are often the first point of contact for those who have experienced violence and require care or treatment for themselves or their children. Worryingly – but unsurprisingly – we found that this was the first time these young women had had an opportunity to discuss either gender or sexual violence; several of them were hesitant to even use the words ‘rape’ or ‘sexual harassment’. This experience illustrates a genuine gap in India’s response to gender violence – inadequate training for healthcare professionals.

The irony is that abused women seek and receive more health care than those who have not experienced violence in their lifetime. The public and private health care system in a country therefore can and must play a vital role in recognising, recording, responding to and documenting instances of gender violence.

Right from the moment a woman enters a health facility with a violence-inflicted injury (irrespective of the severity), every department in that facility has a specific responsibility. This includes doctors on duty at the emergency ward, nurses, gynaecologists, obstetricians, forensics specialists, counsellors, psychiatrists and psychologists. In such cases, their job does not end with merely offering the woman the necessary treatment. They must, first of all, learn to recognise gender violence; equally, they must remember that a woman may seek health care for her injuries, but most often, will not choose to disclose an experience of violence. They must know how to respond to a woman who has been raped or abused, by choosing the right words. What can they say? What should they not say? They must understand their role in helping women seek justice through meticulous and sensitive documentation.

In other words, responding to gender and sexual violence is no ordinary or easy task. It requires knowing how to use a rape kit so as not to cause any further trauma. It requires an understanding of the complexities of violence and the emotional impact it has on those who experience it. It requires a non-judgemental attitude; it is not, for instance, the health worker’s responsibility to verify or question the authenticity of an allegation of sexual violence. It demands discretion and respecting an individual’s confidentiality. It needs, therefore, both the right skills and the correct attitudes.

VAW Health Workers

Source: http://www.who.int/reproductivehealth/publications/violence/VAW_WHO_Intervention.jpeg?ua=1

The guidelines and protocols exist. In 2003, the World Health Organisation (WHO) published ‘Guidelines for medico-legal care for victims of sexual violence’, outlining the roles and responsibilities of the health sector, particularly in treating rape victims.  It draws attention to the range of services needed, including pregnancy testing, emergency contraception, STI services and psychosocial counselling. It emphasises the responsibility of health care professionals in gathering evidence that can help identify and punish a perpetrator.

In 2013, the WHO published a new set of clinical and policy guidelines on “Responding to intimate partner violence and sexual violence against women”.  At the Sixty-sixth World Health Assembly held in May last year (2013), seven governments – Belgium, India, Mexico, Netherlands, Norway, United States of America, and Zambia – declared violence against women and girls “a major global public health, gender equality and human rights challenge, touching every country and every part of society”.

In India, CEHAT has done pioneering work on health sector responses to sexual violence and assault. Last year, the Government of India issued its own set of guidelines, developed by the Ministry of Health and Family Welfare on medico-legal care for survivors/victims of sexual violence.

All these documents are potential blueprints, waiting to be included in the code of conduct and practices of private hospitals and clinics that operate throughout the country. They are also waiting to be incorporated into medical and nursing college curricula.

The idea that someone who has been raped is shuttled back and forth between the police and the healthcare system is hard to accept. And really, why should we accept it? The act of violence, whether rape or domestic violence or sexual assault, is unjust in the first place. The lack of proper response mechanisms to support someone who has experienced this violence only accentuates the ‘unjustness’ of the situation.

It is well past time to put these guidelines into practice and to move from words to action.

[1] Violence against Women: The Health Sector Responds. WHO (2013). Accessed at http://www.who.int/reproductivehealth/publications/violence/NMH_VIP_PVL_13_1/en/

NB: An earlier version of this post appeared in The Alternative.

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Anupama Srinivasan works on issues related to public health and gender. She’s been Programme Director of the Gender Violence Research and Information Taskforce at Prajnya since 2010. She can be contacted at anupamasrinivasan.prajnya@gmail.com

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