Kathmandu, Nepal—The Government of Nepal is working to change a code of silence that surrounds gender-based violence (GBV) by establishing guidelines and protocols for health workers who are on the frontlines of care for women.
This month, I traveled to Nepal to support the Government’s leadership in this area, and assist in drafting the protocols to address this very newly recognized, but critical women’s health issue in the country. Like so many women around the world, Nepali women face high levels of violence. Recent studies in Nepal have found that roughly half of women experience some form of violence, be it emotional, physical, sexual or economic. The overwhelming majority of the perpetrators are the woman’s spouse or partner. And, as occurs elsewhere in the world, most women do not report their experiences of violence to anyone, but rather accept it as their “fate” or the norm.
The Ministry of Health wants to change this paradigm by developing GBV guidelines and clinical protocols for health care providers. Facilitated by Jhpiego, with support from UNFPA, a team of experts met to review and refine the ongoing work on the GBV clinical protocols.
One challenge was evident from the start—protocols for GBV must take into account not only medical issues, but also legal and psychosocial issues, and considerations of safety for the client.
Here’s a case in point: Nepal’s laws mandate that in cases of sexual violence, attempt to murder and life-threatening or grievous injuries, health care providers must report cases that they encounter to the police. But the law does not always represent the desires of all GBV survivors. The reality is that most women do not want to report cases of violence to the police, due to shame and fear of rejection by their family and society. As a result, many women prefer not to receive a medical exam or treatment to avoid their cases being reported to the authorities or being exposed in the community.
The culture of silence surrounding GBV is not something that is perpetuated by women themselves. It is fueled by the attitudes and behavior of all members of the family, community and social networks—the neighbor who turns a silent ear; the mother who encourages the abused woman not to say anything that would shame the family; the local community leader or group that merely settles the current dispute, but doesn’t address the issue of violence; the police officer who re-victimizes the abused; and even the health care provider who doesn’t ask about violence when the signs are clear.
Not reporting violence to authorities, by some views, may result in being complicit with this culture of silence. As legal experts pointed out during the GBV protocol review meetings, there is a universal legal obligation for health care providers to report violent criminal offenses. On the other hand, the violence that women face has grave effects on their health. For example, a study in Nepal found that rural women who have experienced GBV have significantly more reproductive health problems and are 10 times as likely to attempt suicide. Health care providers have a key and ethical role in not only identifying violence and properly treating it, but also conducting a medical exam and completing documentation to present evidence of criminal violations, such as rape, to the legal authorities.
How can health care providers ensure that they meet both legal and ethical medical obligations for treating GBV survivors?
These are challenges faced by health care providers worldwide as countries begin to establish formal health services for GBV survivors. The law of the land must be respected. However, health providers must be trained also to be as sensitive to the needs of survivors as they can within this framework, including educating them about legal issues and rights, to both give survivors the medical care they need, as well as play their role in breaking the silence about GBV.
After our work, the team—government representatives and legal, medical and psychosocial experts—believes we have a lot to be positive about.
Formal policy frameworks on GBV in Nepal are nascent. And yet, the partnership of government, donor, international non-profit organizations and professional groups in this process resulted in a rich document reflecting the expertise of various experts and sectors, as well as Nepal’s legal and institutional frameworks. As the global health community and women advocates mark International Day of Elimination of Violence Against Women on November 25, Nepal is doing important work in this arena.
Jhpiego Nepal is looking forward to finalizing the protocol and guideline by the end of this year ultimately to help catalyze a more formalized, health system-wide response to GBV in Nepal.