Health Care Workers Matter for Gender Based Violence

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.

The role of health professionals goes beyond simply treating and healing a survivor of gender bases violence – we can empower them, too.

Vestibulodynia? I’d Never Heard of it Either

If you don’t know how to pronounce Vestibulodynia, let alone have any idea what it is, don’t worry – for a long time, I didn’t either.

You may have heard of another term – Vulvodynia – though you’re probably not sure what that means either. This is the term given to generalised, unidentified pain in the vulva. Women are often diagnosed with Vulvodynia when their doctor is unsure of why they are in pain.

There are also scenarios – which I have personally experienced – where doctors don’t offer any diagnosis at all, and instead see pain in the vulva as something psychological.

When this happened to me, I was told to go and see a Psychosexual Counsellor to deal with the pain I experienced during sex. But I was so confused – if I’m physically in pain, how is this going to help me? I did my best to go to my appointment with an open mind, as no other doctor could seem to give me any further insight.

It was suggested that I had Vaginismus – a condition that causes the vaginal muscles to tighten involuntarily during penetration, or even when inserting a tampon. The idea behind attending counselling to deal with vaginismus was that I could talk about any mental worries to do with sex, practice mindfulness, and hopefully then feel more relaxed so my ‘involuntary tightness’ would fade away.

I remained convinced, however, that my pain was very much physical and I felt sure that I just hadn’t found the correct diagnosis yet. I was trying to be as open minded as possible, in the hope that I could ‘talk’ my way out of the last 8 years of pain, but after 10 Psychosexual Counselling sessions I decided that it wasn’t for me.

My counsellor was a wonderful and empathetic man, but I really couldn’t shift my belief that I did not, in fact, have some deep-rooted traumatic issue that I related to sex. My search for help continued.

Endometriosis, irritable bowel syndrome (IBS), severe period pain, internal cysts – I was scanned and tested for so many things. It was a long, arduous, frustrating process with which I know many other women can identify. I’ve spoken to women who felt they were being ‘passed around the system’, as well as others who felt as though they’d been completely given up on.

I’d done a huge amount of research on my own about what I was experiencing, but after a while I realised that I hadn’t actually researched individual professionals working in the field of vulval pain.

I finally booked an appointment with a well-researched specialist, who confirmed within 15 minutes of talking to me that I had Vestibulodynia – a condition that causes severe pain around the vestibule, the entrance of the vagina. This pain can occur from vaginal entry such as intercourse or using a tampon – which is how I was affected, but some women experience pain purely from pressure around the area, such as from wearing tight fitting clothes, or riding a bike. My heart truly goes out to any woman experiencing this.  

The symptoms and the level of pain vary greatly amongst sufferers, and as there seem to be so many varieties, I can understand why it can be hard for medical professionals to diagnose the condition. There’s a difference between provoked and unprovoked Vestibulodynia, for example, which means that the pain can occur with or without touch. Some women physically tear during sex, while others have red irritated skin.

The experience that all women suffering from the condition seem to share is the burning sensation, likened to being cut with a razor or having acid poured on the skin. I am amazed, and horrified, that so many women have to experience this level and intensity of pain and yet the rate of diagnosis remains so low. Many gynaecologists are still completely unfamiliar with the term.

Since my diagnosis, I have had surgery to try to improve my condition. After countless other treatments, I decided this was the best option for me, but most women aren’t even given surgery as an option. Most women have to deal with this condition – and countless other vulval disorders – with such a complete lack of support, for so many years, before coming anywhere close to a diagnosis.

Why, as women, are we so ill-informed about this element of our health? Why is our pain so often dismissed and de-validated? Why is the silence surrounding women’s bodies and sexual health still so stifling? 

Personally, I found reading blogs from other sufferers incredibly important. Reading other people’s words gave me an insight into their pain and ideas of things I could try for myself. Most importantly, reading blogs made me feel – for the first time – that I really wasn’t alone.

Unfortunately, there’s no guarantee that one person’s experience will be exactly the same as the next’s, so there’s no assurance that you will find all of your answers in another woman’s blog post. But from my own experience, what you will find is a community and support network that is doing its very best to provide the answers that the medical professionals can’t or won’t. 

To anyone who is suffering and to anyone who is currently in pain: keep strong, keep searching – your answer will be out there. And in the meantime, I promise you that support from other women experiencing a similar thing is far more comforting than going it alone.

Why Mothers Need More Than a Hospital

In rural Nepal, pregnancy is referred to as a “gamble with death.”

Possible-Rupa-Photo
Photo Credit: Possible

Rupa nearly lost the gamble. She was born in her own home, but her mother warned her of the dangers of home births. Rupa, like so many other pregnant women, wanted to give birth in a safe healthcare facility near her home.

When she went into labor, she immediately journeyed to the nearest clinic. There was only one midwife present and part way through her delivery the nurse suspected complications.

Rupa knew she needed additional help.

Rupa is from a district called Mellekh, which is a two-hour drive over rough roads to our hospital in Bayalpata—a drive that is impossible to make during the monsoon season because of the road conditions. Rupa called for an ambulance. Possible’s ambulance driver came to pick her up and bring her to our hospital in time to safely deliver a baby boy.

Rupa’s story has a happy ending. She gave birth to a beautiful baby boy after an intense labor and the imperative help of two of our midwives. Mothers who are fortunate to be close to a hospital can also experience safe and healthy deliveries. Without having trained staff and professional services, the baby could have died. At Possible’s hospital hub in rural Nepal, the number of births taking place within the facility has grown over 900% since 2010. We believe a hospital is not enough.

What pregnant women really need, in a region with one of the highest maternal mortality rates in the world, is access to safe birthing centers closer to their homes and support throughout their pregnancies.

Which is why Possible exists, and why we have pioneered an approach called Durable Healthcare that puts safe births at the center of our integrated model. It is also why the percentage of women delivering in health facilities is one of our six Key Performance Indicators.

We solve the problems of pregnant mothers like Rupa by having female community health workers provide training and referral support in villages. The health workers coordinate with local community governments to transform clinics into safe birthing centers and link clinics to a central hospital with ambulances for emergency deliveries.

This model is supported financially through a partnership with the Nepali government’s Safe Motherhood Program, where both pregnant mothers and Possible receive payments for attending prenatal care visits and delivering in a health facility. It is a model of safe births that works fully for pregnant women, not partially—a model that ensures all mothers can have a happy ending like Rupa.

This post is from one of our partners. Possible, is a healthcare company that delivers high-quality, low-cost healthcare to the world’s poor.