|Year : 2013 | Volume
| Issue : 1 | Page : 4-7
Gender-violence and health care: How health system can step in
Suneela Garg1, Ritesh Singh2
1 Director-Professor, Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
2 Assistant Professor, Department of Community Medicine, College of Medicine and JNM Hospital, WBUHS, Kalyani, West Bengal, India
|Date of Web Publication||4-May-2013|
Assistant Professor, College of Medicine and JNM Hospital, WBUHS, Kalyani, Nadia, West Bengal
| Abstract|| |
Gender-violence also known as domestic violence, domestic abuse, spousal abuse or intimate partner violence, can be broadly defined as a pattern of abusive behaviors by one or both partners in an intimate relationship such as marriage, dating, family, friends or cohabitation. It can manifest as physical aggression, sexual abuse, emotional abuse, intimidation, stalking and economic and food deprivation. In most countries gender violence is a crime; though scope of the domestic or gender violence act and severity of punishment varies considerably between the countries.
Keywords: Domestic violence, Gender violence, Health care
|How to cite this article:|
Garg S, Singh R. Gender-violence and health care: How health system can step in. Indian J Public Health 2013;57:4-7
|How to cite this URL:|
Garg S, Singh R. Gender-violence and health care: How health system can step in. Indian J Public Health [serial online] 2013 [cited 2014 Dec 19];57:4-7. Available from: http://www.ijph.in/text.asp?2013/57/1/4/111355
| Introduction|| |
Gender-violence occurs across the world, in various cultures, and affects people across society, irrespective of economic status. Awareness, perception and documentation of gender-violence differ from country to country. In South Africa, research has found that between 25% and 55% of women have experienced physical intimate partner violence (IPV).  Data from National Family Health Survey-3, India, a large nation-wide survey, shows that around 37% of ever-married women have ever experienced spousal violence.  The World Health Organization (WHO) multi-country study on women's health and domestic violence against women collected data from over 24,000 women from 15 sites in 10 countries representing diverse cultural settings.  The proportion of women who had ever experienced physical or sexual violence, or both, by an intimate partner in their lifetime, ranged from 15% to 71%. The study also shows that two thirds of women who had been physically abused by their partner in Bangladesh, and about half in Samoa and provincial Thailand, had not told anybody about the violence prior to the interview.
| Health Issues Related to Gender-Violence|| |
According to the Center for Disease Control and Prevention and WHO, gender violence is a serious, preventable public health problem, with far reaching health consequences. The fifth version (to come out in 2013) of Diagnostic and Statistical Manual of classification of mental disorders will have a series of new "Relational disorders" which will include "marital conflict disorder without violence and marital abuse disorder."  Women do not easily come forward for treatment. On average, women experience 35 incidents of domestic violence before seeking treatment. 
Around the world, mental health problems, emotional distress, and suicidal behavior are common among women who have suffered partner violence.  In the WHO multicentric study, women who had ever experienced physical or sexual violence, or both, by an intimate partner reported significantly higher levels of emotional distress than non-abused women. Likewise, in all settings, ever-partnered women who had been abused by their partners were much more likely to have ever thought of suicide and to have attempted it than non-abused women.
Risk of getting infected with Human Immunodeficiency Virus (HIV) is more in women who experiences violence in their home. Kristn L Dunkle  has assessed gender-based violence as a risk factor for HIV after adjustment for women's own high-risk behaviors in a cross-sectional study of women presenting for antenatal care. After adjustment for age and current relationship status and women's risk behavior, IPV and high levels of male control in a woman's current relationship were associated with HIV seropositivity.
| Reproductive Health and Gender-Violence|| |
A case control study has shown that women experiencing IPV were more likely to report not using their preferred method of contraception in the past 12 months compared with non-abused women (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.0 to 3.7) which can result in unintended pregnancies among abused women.  Analysis of data from the 2000 demographic and health survey for Colombia has shown that if IPV alone is eliminated an estimated 32,523-44,986 fewer unintended pregnancies would result in Columbia. The study showed that women's adjusted odds of having had an unintended pregnancy were significantly elevated if they had been physically or sexually abused (OR, 1.4).  A study comparing the causes in spontaneous and induced abortion cases shows that women opting for induced abortion were more likely to have a recent history of domestic violence (OR: 18.7, 11.2-31.0) after adjusting for age, pregnancy intention and marital status. 
| Role of Health Systems in Combating Gender-Violence|| |
Medical professionals can make a difference in the lives of those who experience abuse. They are in position to empower people, give advice, and refer them to appropriate services. Many cases of spousal abuse are handled solely by physicians and do not involve the police. Majority of the cases are handled by family physician or other primary care provider. Many doctors prefer not to get involved in people's "private" lives, so they do not go into the details of this aspect of history taking. Training about domestic violence in medical school is very limited and in many places they are totally absent. Sadly, neither the doctor goes into the cause of the injury inflicted on a woman, nor there is willingness of victim to come forward and broach the issue with their physician. 
This seems to be uphill task for starters but once in place would definitely help break the barrier of communicating violence to the health care providers. Every health care center should identify a Non-Governmental Organization (NGO) working for the women in their vicinity. The health centers only need to send the woman to the identified NGO and inform the organization about such cases. The NGO can take the case further as they have their own legal representative and are liaising with the police station. The Prevention of Women against Domestic Violence (PWDV) Act 2005 has provisions of a Protection Officer in every area. They can also be contacted if the health center comes to know of any such case.
| Screening the Women Attending the Health Care Facility for Gender-Violence|| |
Doctor, nurse or other para-medical staff in the health care facility can ask some leading closed-ended question regarding gender-violence to all adult female patients attending the outpatient department and the emergency room. Although, nurses are in a unique position to screen for domestic violence and provide assistance and advocacy for victims, barriers exist related to victim disclosure and staff training and comfort levels. Advanced practice nurses can address the issue directly through appropriate treatment facilitation, including both physical and psychosocial intervention. 
Integrated Counseling and Treatment Centre for HIV is an excellent place to make women speak of violence against them. Christofides  conducted a qualitative study to explore women's experience of IPV screening in voluntary counseling treatment (VCT) services in Johannesburg, South Africa, and explored implications for VCT counseling. Findings suggest that women were supportive of being asked about their experiences of IPV during VCT sessions. Reasons for supporting IPV screening at VCT services include the limited access of many women to health services. Many women who were aware of their HIV risk felt powerless to discuss condom use, HIV testing, and infidelity with their male partners. Women directly related such experience of gender power inequality to HIV risk.
The doctors, nurses and para-medical staff should be properly trained and sensitized to gender-based issues. Once a woman is found out to be suffering from gender-violence, she should be properly referred for counseling from a counselor trained in gender based issues. The help of police and judicial system should also be sought as and when needed. There are around 300 medical colleges in India. One rural and urban center is necessarily attached with the Department of Community Medicine of these colleges. The department provides outreach health activities to the population residing in its catchment area. The Department of Community Medicine along with related department like Obstetrics and Gynecology, Pediatrics and Orthopedics can play an important role in the screening of women for domestic violence attending the health center. The Department of Forensic Medicine can be roped in to make the detailed injury report.
A study support the view that the women attending the health center should be asked about questions related to IPV. Seventy five per cent of all respondents felt that doctors and nurses should ask women whether they were being hurt or felt unsafe in the relationship. Those who had experienced IPV were significantly more likely to support screening by health care providers. 
A "systems model" was developed using tools for effective referral, evaluation, and reporting of domestic violence to see whether there is increased screening for domestic violence by clinicians; increased awareness of the healthcare facility as a resource for domestic violence assistance; and increased patient satisfaction with the health plan's efforts to address domestic violence. The number of clinician referrals and patient self-referrals to an on-site domestic violence evaluator increased more than twofold. 
| Conclusion|| |
Gender based violence is a burning issue which cannot be solved by one agency. A concerted effort involving health care providers, NGOs, judiciary and government can only prevent it. Even if it is not prevented an alert system would ensure that the offender is recognized and does not get unpunished. Health system can play a pivotal role and a link between the abused and the judiciary. Health care providers not only help the woman get medical help but can also prevent future abuses by reporting to proper authority.
| References|| |
|1.||Dunkle KL, Jewkes RK, Brown HC, Yoshihama M, Gray GE, McIntyre JA, et al. Prevalence and patterns of gender-based violence and revictimization among women attending antenatal clinics in Soweto, South Africa. Am J Epidemiol 2004;160:230-9. |
|2.||National Family Health Survey. Key Indicators for India: NFHS 2005-06. Available from: http://www.rchiips.org/NFHS/pdf/India.pdf. [Last Accessed on 2012 Mar 12]. |
|3.||World Health Organization. Initial results on prevalence, health outcomes and women's responses. Summary report: WHO Multi-country Study on Women's Health and Domestic Violence against Women. World Health Organization; 2005. p. 6. |
|4.||First MB, Bell CC, Cuthbert B, Krystal JH, Malison R, Offord DR, et al. Personality disorders and relational disorders. In: Regier DA, Kupfer DJ, First MB, editors. A Research Agenda for DSM-V. Washington, DC: American Psychiatric Association; 2002. p. 164-6. |
|5.||Bowen, Erica, Brown L, Gilchrist E. Evaluating Probation Based Offender Programmes for Domestic Violence Perpetrators: A Pro-Feminist Approach. Howard J Crim Justice 2002;41:221-36. |
|6.||Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, editors. World Report on Violence and Health. Geneva: World Health Organization; 2002. |
|7.||Dunkle KL, Jewkes RK, Brown HC, Gray GE, McIntryre JA, Harlow SD. Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. Lancet 2004;363:1415-21. |
|8.||Williams CM, Larsen U, McCloskey LA. Intimate partner violence and women's contraceptive use. Violence Against Women 2008;14:1382-96. |
|9.||Pallitto CC, O'Campo P. The relationship between intimate partner violence and unintended pregnancy: Analysis of a national sample from Colombia. Int Fam Plan Perspect 2004;30:165-73. |
|10.||Kaye DK, Mirembe FM, Bantebya G, Johansson A, Ekstrom AM. Domestic violence as risk factor for unwanted pregnancy and induced abortion in Mulago Hospital, Kampala, Uganda. Trop Med Int Health 2006;11:90-101. |
|11.||Sugg NK, Inui T. Primary care physicians' response to domestic violence. Opening Pandora's box. JAMA 1992;267:3157-60. |
|12.||Carretta CM. Domestic violence: A worldwide exploration. J Psychosoc Nurs Ment Health Serv 2008;46:26-35. |
|13.||Christofides N, Jewkes R. Acceptability of universal screening for intimate partner violence in voluntary HIV testing and counseling services in South Africa and service implications. AIDS Care 2010;22:279-85. |
|14.||Miller E, Decker MR, Raj A, Reed E, Marable D, Silverman JG. Intimate partner violence and health care-seeking patterns among female users of urban adolescent clinics. Matern Child Health J 2010;14:910-7. |
|15.||McCaw B, Berman WH, Syme SL, Hunkeler EF. Beyond screening for domestic violence: A systems model approach in a managed care setting. Am J Prev Med 2001;21:170-6. |