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.

Family Planning Realities for Young People in Nepal

In many developing regions, young people still lack access to safe and effective family planning methods, for reasons ranging from lack of information or services to lack of support from their partners or communities. Young people are still being prevented from making informed autonomous decisions about their lives and their bodies.

Speaking from my own experience in Nepal, values about sexuality vary and are defined by culture and religion. One common barrier is social stigma, which discourages young people from openly discussing their needs and seeking the necessary interventions.

Nepal is one of the countries with fairly high adolescent fertility rates. Age at marriage is an especially important variable shaping fertility levels in Nepal, since it is a society where premarital sexual involvement is strongly disapproved of. The high rate of adolescent childbearing is a result of early age at marriage among women.

Nepal Demographic and Health Survey data reports some encouraging trends, such as the progressively increasing age at marriage over the past 15 years. However, there has not been a similar increase in the age at which adolescent girls begin childbearing.

In Nepal, the level of unmet need for family planning remains high.

Some adolescents cannot afford to pay for services, and even if they can, many fear that they’ll be required to provide parental consent before they can actually receive those services.

Young people have the right to make informed decisions about their lives. Integrating their perspectives and helping them overcome the social, legal and practical barriers they face is critical to achieving the goals of Family Planning 2020 (FP2020).

The Government of Nepal is committed to improving health outcomes in the country, and several policies and strategies have been put into place. The recent initiatives by government to provide family planning services through satellites and mobile clinics as well as community health volunteers is commendable to expand the reach of services in area of low accessibility.

Despite significant efforts, the idea of offering family planning services to young people is still not well accepted and easy to advocate for in Nepal. 

In advocating for young people’s rights to access family planning, factors such as age, religion, livelihood and education need to be taken into account. It is also true that young people are often more likely to seek information about reproductive health from informal sources.

Accordingly, to advance progress, information should be provided through media, peers and informal sectors. Peer education can be an effective in facilitating young people’s access to sexual and reproductive health (SRH) services and influencing social norms. Providing adolescents with Comprehensive Sexuality Education (CSE) has been shown to improve adolescent sexual reproductive health knowledge, attitudes, and behaviors when implemented well.

Adolescents and youth constitute a large section of the population in Nepal. Given its size and likely trajectory of growth in the future, this population warrants a focused policy attention, especially when it comes to education, health and population. Adolescents make up a high percentage of Nepal’s total population, and so policies and programs in family planning and reproductive health will have to be expanded to meet the needs of these groups.

For adolescent SRH programs to be effective, we need substantial efforts from the government along with the non-governmental organizations and the private sector. Unproductive approaches should be abandoned, proven approaches should be implemented. New approaches should be explored that better respond to adolescents’ needs.

We must commit to providing young people with the tools to take action in their communities and identifying funding opportunities for youth-led efforts.

As we continue to build the framework for Universal Health Coverage, we must ensure meaningful and sustainable youth engagement on family planning at all levels.

Nepalese Women are Dying in the Name of Tradition

Last week, an eighteen-year-old girl died in a menstrual hut in Achham, a remote far western district of Nepal, according to a news report.

In August 2017, Nepal’s parliament passed a law criminalizing a deep-rooted tradition called Chhaupadi which forces women to leave their homes and stay in a ‘menstruation hut’ during their period. However, this most recent death suggests little or no progress has been made in implementing the new law.

Parbati Budha was bitten twice on her finger by a venomous snake while banished during her period. There was no one nearby to take her to the hospital immediately after the snakebite as her parents and neighbors were far from the menstrual hut. As a result, she was deprived of the medical treatment that would have allowed her to survive.

This is a painful incident. Even more painful is the fact that that no one can say for sure that this death will be the last.

In January this year, 22-year-old Gauri Budha was found dead by her neighbors inside a menstrual shed. In July 2017, Tulasi Shahi, 19, was bitten twice by a venomous snake and died. On 18 November 2016, 21-year-old Dambara Upadhyay from Timilsen village was discovered dead in a hut while 15-year-old teenager Roshani Tiruwa of Gajra died on 17 December of the same year.

Exact figures are difficult to find as statistics are not well-maintained by the government, but it is believed that dozens of women die every year across Nepal in the name of tradition.

Generally, menstrual huts are constructed away from homes so that menstruating women are out of sight and unable to touch male members of households. Most menstrual huts are single-room buildings with small doors. Huts either have no windows or very small ones, and poor sanitation and ventilation.

As a result, women can die from suffocation or from snake or scorpion bites. During a visit to various districts in western Nepal, I spoke with many women and girls who shared their fears of being attacked by wild animals and snakes while isolated in menstrual huts.

Taboo and stigma surrounding menstruation is deep-rooted. In some parts of the country, menstruating girls are not allowed to eat with their family members, nor are they allowed to enter the kitchen. They are forbidden from touching male members of the family, as well as neighbors, cattle, and growing fruit and vegetables. Seclusion is practiced in its most extreme form in mid and far western regions of the country, where menstruating women are banished to sleep in a shed.

In my observation, there is not one single reason behind menstrual taboo and stigma. Instead, multiple factors have contributed to the continuity of this inhumane tradition.

The first reason I found for menstruating women following the practice is their fear that if they don’t, the Gods will be angry and will bring misfortune to their family. Another reason is fear of isolation from society. I don’t think any parents actually want their daughters to sleep in cow sheds, but they cannot stand against the tradition as they fear the isolation from society that would result.

The government should make a strong commitment to ending this inhumane practice of secluding menstruating women. The tradition is claiming lives of many women and girls, and it’s the responsibility of the government to provide more than just lip service to end all forms of discrimination against women and girls.

After hearing each news report on the death of a woman or girl in a menstrual shed, I ask myself: how many more women must die before social mindsets and attitudes change?

This question troubles me. The government must realize that the country cannot afford the cost of inaction. Sincere efforts from all concerned stakeholders are required to ensure a society where no woman is banished to sleep in a shed because of an unavoidable, natural process. The government should not remain indifferent to the pain and suffering the women of Nepal face while following the Chhaupadi ritual and facing its consequences.

Smashing taboos around menstruation is about upholding women’s rights and dignity. I disown the whole culture of menstrual restrictions, as I believe that no culture, religion or country has the right to dub a woman’s period a ‘sin’ or ‘impure’. Periods are natural. Banishment and seclusion of women for a natural biological process is nothing more than superstition. It’s time to debunk the myths surrounding menstruation to ensure that no woman should suffer again.

If not us, who? If not now, when?

A Day in the Life of a Working Nepalese Woman

This post was written by 2016 LEADer and Women LEAD Blogger, Samika Mali

Whether it is a weekday or weekend, my mom wakes up every day at 6am and sweeps the entire house. Preparing lunch every morning until 9am is a compulsion for her no matter how sick or weak she is. Then, in no time, she has to gulp down her lunch, get dressed, and rush to work.

After a long day at her shop, she returns home tired and exhausted. But she doesn’t get to rest. Though her duties as a businesswoman are over, her responsibilities as a housewife have not ended yet. In the evening, she has to serve food to all her family members and do the dishes. Then, she cleans the whole kitchen. Sometimes, she even mops the floors, throw the clothes in the machine to wash, and sits down to help me with my projects. Finally, her day ends.

Growing up, I saw my mother balance her life as a successful business woman in a culture where women are expected to limit themselves within the four walls of the house. A few years ago, my mother decided to work alongside my father in his business, even though she was highly criticized by my grandparents, who asked her to stay home. But she refused to be silenced and instead raised her voice against social taboos in order to pursue her career.

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In our Nepalese society, once a women gets married, she can’t keep herself away from all these responsibilities. Wearing a red bridal dress, a woman promises her new husband to be his partner for life and adjusts herself in his family, leaving her own parents behind. It’s a common story of every Nepalese woman. Her new life can bring her tons of happiness, but along with that she gets many new responsibilities— responsibilities of a daughter-in-law, a wife, and a mother. She works 24 hours a day, 7 days a week as a caretaker, a cook, and a cleaner without expecting anything in return.

A woman sacrifices her surname, sacrifices her beloved parents, and sacrifices her body to be pregnant. And only a woman does it.

 

After marriage, my mother says that a woman compromises in ways that a man would never think of, especially when it comes to her career. The dedication, effort, and hard work that she used to invest in her job before marriage is now invested in doing all her household chores. The promotion that she deserves based on her ability and skill is given to another man just because she can’t afford to be away from the home for any extra hours or because she wants to avoid the additional workload. In Kathmandu Valley today, men are rarely expected to make the same compromises.

received_655684851260830Though we live in 21st century, and Nepal is a federal democratic country where women and men have equal rights by law, the traditional thinking of the people hasn’t changed yet. The social structure of our society discourages married female members of their house to go out and work competing against male members. They are expected to look after the house and rear children rather than to do a job or run a business. People should understand that the economic contribution of both women and men is necessary for a country to progress. And only a change in our culture shall ensure this can happen.

Affording a healthy, balanced, and satisfied life in this era is a big challenge. So, gender equity in both workplace and household chores should be maintained. A working woman not only supports her family financially but she can introduce good cultures too. A working woman most probably is educated, has a skill and meet new faces everyday. Thus, she knows better culture, she is independent and she can deal with problems effectively.

My mother says, “In Nepal, after a woman is married, there are so many boundaries set for them not only in terms of work but also their dress code, lifestyle and more. Thus, we ought not to stay quiet, but fight against the society to get our right and freedom, we have to raise our voice to be equally treated in the family as well as community and we have to be strong enough to eradicate male dominance in the society.”

Because of my mother, I know that a woman can be a great parent and a successful entrepreneur at the same time. But if women are not given equal rights, treated equally, or allowed to contribute to the  workforce, then our country cannot develop. A country cannot progress if they are not willing to acknowledge half of the population as equal. Women must be encouraged to participate in entrepreneurship, contribute new ideas, and involved in the workforce. This will ensure both the development of Nepal in one hand and progress for women in another.

Featured image: Robert Stansfield/DFID (Creative Commons)

Images inside text by author.

Unequal: How Nepal’s Citizenship Laws Prevent Young Women from Achieving Their Dreams

By Bidhyalaxmi Maharjan, Women LEAD’s Communication Intern

Life has never been easy for Reni.* When her father died of cancer, she took over her family shop, but it was very difficult for her family of seven to live on the shop.  Later, when an acquaintance offered her a job at a finance company, she was more than happy to get a job that paid her 7,000 rupees, or $70, a month. But she did not get the job for one reason—she was not a Nepali citizen.

That was the first problem among hundreds of others Reni would go through following the death of her father. While Nepali fathers are able to pass citizenship to their children regardless of their wives’ nationality, Nepali mothers who are single or married to a foreign partner are not afforded the same right. Their children can then either live their life as a stateless person, or navigate Nepal’s complex bureaucracy in an attempt to become citizens of their country. Reni was too young to file for citizenship before her father’s death (you must be 16), and she now had no way to prove she was his daughter. She has since made rounds at the offices of the Chief District Officer in Bhaktapur to try to get citizenship, not just for herself but also for her two younger brothers and sister.

“I feel excluded from all the services the government provides to its citizens. I wanted to continue my studies. I had dropped out of high school. I thought of applying for a scholarship, but I knew I would not get it, because I did not have citizenship,” she explained.

It’s not just the government that has attempted to deprive her from acquiring citizenship—Reni’s family has also tried to force her to get married in order to obtain the proper documentation. “Even my own brothers have such a concept. I faced a lot of pressure to get married. They would not have submitted my application in a recent bid to get citizenship, if I hadn’t insisted. They don’t acknowledge it as my problem at all.”

Unlike men, Nepali women and girls face a number of different issues in their attempts to become citizens. Many people believe marriage is a simple “out” when it comes to obtaining citizenship for their daughters, though it is hardly a solution.

“If the woman acquires citizenship through her husband by specifying his name on the marriage certificate, then she will need to change [her last name] again if she gets divorced later,” explains Subin Mulmi, who has been actively advocating for Nepali women’s right to pass on the citizenship to their children. “The name of the husband will be removed and the surname of the husband will also be removed,” added Mulmi.

Anuja* faced the similar plight when her father refused to verify that she was his daughter after her parents’ marriage ended. “My mother got married when she was 19. My parents separated after I was born though they did not divorce formally. My maternal grandparents brought me up. What I couldn’t see is why my identity was being tied so closely with my father. My mother has invested in me, but during my struggle to get the citizenship, I felt as if my mother had nothing to offer me.”

According to the existing constitutional provision, it is mandatory for a divorced Nepali woman to either identify her husband or prove that the father of the child is unknown in order to pass on citizenship to her child.

Not possessing citizenship can be a huge obstacle for young Nepalis, especially women. Many Nepalis brought up by single mothers spend years battling to get the proper documents. Citizenship is required to get higher education, get jobs, and go abroad. “I wanted to go abroad, but since I didn’t have citizenship, I thought I can’t make passport. I feared I would be treated unfairly in college because I did not have citizenship,” said Anuja.

As Nepal celebrates the first anniversary of the promulgation of the constitution this week, thousands of Nepalis like Reni and Anuja feel that they are not equal in the eyes of their government. They cannot follow their dreams because they do not possess citizenship, even when they as Nepali as any of us.

*Names have been changed.

Featured image: Stephan Bachenheimer/World Bank (Creative Commons)

Climbing Bravely Above Expectations

We were above the clouds, pushing through the most technical part of the climb (appropriately named Disappointment Cleaver) up Washington’s Mt. Rainier. The rope running out from my own harness was linked to one in front and one behind. Together, my rope team of three scrambled through rock and ice. In front of me was my guide, Pasang Sherpa, who moved with the ease of being at home in the mountains. I did my best to emulate her effortless movements up through feet of fresh snow, following her lead as professional climber and mountaineering guide.

Pasang is Sherpa, a particular people group of the Himalayas of Nepal so well known for their climbing abilities that people often associate the word “Sherpa” with a porter who carries gear up peaks for foreign climbers. But not all Sherpa people are climbers. Rather, for many Sherpa women, the expectation is not to live up to the same expectation as for Sherpa men to be incredible high altitude climbers.

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Sarah and Pasang on Mount Ranier

In Pasang’s Sherpa community, like much of Nepal where gender disparity is high, girls are expected to take on the traditional roles of staying home and starting a family rather than pursuing further education or careers. Witnessing other girls around her become mothers as teenagers, Pasang decided to pursue her own definition of the life she wanted and went on to train and study to be a mountain guide. With two other Sherpa women she successfully summited K2, arguably the most challenging peak in the world and one which only 18 of the mountain’s 376 summiters have been women. “We wanted to show women that if you just follow your dreams, even if you are a woman, you can do anything. Nothing is impossible,” Pasang said. This feat and her incredible work restoring overlooked communities after the 2015 Nepal earthquakes, earned her the people’s choice award for the prestigious National Geographic’s 2016 Adventurer of the Year.

Or consider Mira Rai, who as an 11 year old carried rice up to her Nepali village although she was expected to do chores while her brothers went to school. In her savvy, she realized if she was able to move more bags of rice up the mountain each day, she could sell more. So she started running with 60lb bags (28kg) of rice, a circumstance that shaped her into one of the best ultra-marathoners in the world. Now she runs elite ultra-marathons (50k+).

And she wins.

Physical disposition may leave a majority of women feeling as though they cannot be incredibly strong, but did you know that studies show women generally feel pain more intensely than men?When it comes to competitions requiring endurance, gender becomes nearly insignificant. Pasang and Mira’s efforts in endurance sports exemplifies their boldness to become anomalies to cultural expectations and restorers in their communities when they come down from the mountains. When I struggle to slog up one more hill in training for my own first 50k trail race this fall, I’m reminded of Mira carrying rice and I’m inspired by how she has gone on to become one of the very best in her sport. As I was roped to Pasang on Mount Rainier, I felt free to enjoy the process that mountaineering brings and to continue toward my own ambitions as a climber, celebrating successes and rejoicing in defiance of disappointments. Climbing above the expectations set for women in Nepal, Pasang and Mira show we are all capable to summit above set limitations and finish the race while leaving standards in the dust.

Want to learn more about this adventure? Watch this video!