It was 10:30 pm on a Monday night.
After a long day at work, I was preparing to go to bed. I usually read before I go to sleep and I’d been trying to finish one book for ages but other things kept coming up. I hoped and prayed tonight would be the night, but the universe had other plans – as always.
My cell phone beeped: “Doctor, it’s an emergency.’’
I flung myself out of the bed and tried to reach the hospital as quickly as I could. The patient was a married 27-year-old woman who had sustained major injuries after accidentally burning herself while cooking.
“60 percentage burn,” I deduced, after taking the patient’s history and a physical assessment. But somewhere inside, I knew this wasn’t an accident and I felt sure there was more to the story.
I started with the patient’s family members. Unsurprisingly, upon enquiry they maintained their stance and kept trying to convince me that their daughter-in-law burned herself while preparing the meal for the family. I decided to talk in confidence with the victim, but she was hesitant to break her silence too.
One day, over the course of providing her with routine care, the woman broke down into tears and alleged that her in-laws had set her on fire for dowry.
In a country like Nepal, speaking out about gender-based violence (GBV) is exceptionally difficult because of the shame, stigma and pressure from families and communities preventing victims from reporting abuse and seeking appropriate services.
Victims are often afraid of disclosing or reporting violence because of the consequences they fear will follow.
In turn, silence can aggravate the situation for survivors, leaving them with prolonged mental and physical suffering.
Nepal has a very high incidence of gender-based violence. And while everyone – regardless of gender – can be affected, women remain the main victims. It is difficult to understand the gravity of GBV in Nepal as many of these cases go unreported due to the silence maintained by victims and perpetrators.
GBV remains one of the most rigorous challenges to women’s health and well-being. It can take many different forms, like physical, sexual, emotional or psychological. The causes of gender based violence are multi-dimensional, and include social, political, economic, cultural and religious factors.
Dealing with survivors of GBV can be a very challenging and sensitive task; starting from acknowledging and identifying the violence to asking relevant questions, without being too intrusive or judgmental at all.
Like me, a wide range of health professionals are likely to come into contact with individuals who have experienced GBV. Health workers are in a unique position to help and heal the survivors of GBV, provided they have the knowledge to recognize the signs. Most of the time, health professionals are likely to be the first point of contact for GBV victims.
But are we, as health workers, equipped with the necessary skills to deal with GBV?
While staff and facilities play a key role in health delivery systems for GBV victims, their efforts will have limited impact unless there are specific policies on the issue of GBV to guide the integration of the response to GBV into health care.
One important approach is to specify the role of health care professionals, and to provide guidance and tools. For instance, the World Health Organization has developed guidelines for in-service training of health care providers on intimate partner and sexual violence against women, specifically. The guidelines are based on systematic reviews of evidence, and cover:
• identification and clinical care for intimate partner violence
• clinical care for sexual assault
• training relating to intimate partner violence and sexual assault against women
• policy and programmatic approaches to delivering services
• mandatory reporting of intimate partner violence
The guidelines aim to raise awareness of violence against women among health-care providers and policy-makers, so that they better understand the need for an appropriate health-sector response. They provide standards that can form the basis for national guidelines, and for integrating these issues into health-care provider education.
Sensitizing staff and building their skills on how to recognize and respond to GBV is crucial. Ensuring that services follow human rights-based and gender specific approaches, and are guided at all times by the preferences, rights and dignity of the victim, is important.
Providing adequate infrastructure to ensure the patient’s privacy, safety and confidentiality is also essential. This can be done by providing a private room for consultations, requiring that consultations are held without presence of a partner, putting in place a system for keeping records confidential or giving instructions to staff on explaining legal limits of confidentiality, if any.
Not only are health workers the ones to fix a fracture or heal a burn injury, they can also play the role of advocate by speaking up against injustice in the course of providing routine care.
Health professionals can also assist victims by making them aware of the counselling and legal services available, which is often a part of the recovery process. Gaining the trust of victims is important in this scenario. Community health care workers and midwives, who are often the most trusted members of societies, can use their power to reach women and vulnerable groups to encourage them to break their silence, and to make informed decisions about their bodies and lives.