Kathmandu University Medical Journal (2009), Vol. 7, No. 2, Issue 26, 89-90 Editorial

Violence against women in Nepal: Role of health care workers Joshi SK Assistant Professor, Department of Community Medicine, Kathmandu Medical College, Sinamangal, Nepal

iolence against Women (VAW) is one of the most and Nepal. At least 26 districts of Nepal are considered Vpervasive of human rights violations, denying as areas that have high occurrence of traf cking, and women and girl’s equality, security, dignity, self-worth, the Ministry of Women, Children, and Social Welfare and their right to enjoy fundamental freedoms. Violence provided small grants to task forces in those high-risk against women is present in every country, cutting districts to raise awareness and mobilize communities across boundaries of culture, class, education, income, against traf cking. Similarly, NGOs cite a growing ethnicity and age. is actually internal child sex tourism problem, with an estimated violence against mothers, sisters, , daughters and 5,000 to 7,000 girls traf cked from rural areas to daughter-in-laws. According to UNICEF1 there exist Kathmandu for commercial sexual exploitation6. six kinds of violence against women and girls in South Maiti Nepal is a National led NGO working on rescue Asia, mainly (i) sexual , (ii) incest and by of victims of traf cking at the border between Nepal family members and other, (iii) recruitment by family and and from the brothels in India as well. Such members into prostitution, (iv) neglect by family victims of abuse and rescued women from the brothels members, even to the point of death, (v) feticide and are being provided shelter in a rehabilitation centre infanticide, (vi) demand and abuse. operated by them. Most of those women are suffering from HIV infection and are shunned by own families Most perpetrators of escape persecution under the Nepali criminal justice system. Domestic VAW are underreported in our country, and the Many cases are found where perpetrators of domestic reasons behind underreporting are to save family prestige, violence escape persecution due to ineffective criminal and privacy, fear of husband and mother in-law, love law of Nepal. Population Briefs, a newsletter of the and affection with husband and family members, fear of Population Council2, reports a high level of physical breaking family relation, fear of social traditional and abuse in homes among pregnant women in Nepal. The socio-cultural values, fear of further beating, physically maternal mortality study conducted by Family Health3, assault, marginalization, uncertainty of justice, lack of revealed the higher rate among women of faith in justice and support of other. Men use threats of reproductive age group. Fifty eight percent of women abandonment, seeking sexual grati cation elsewhere, who suffered domestic violence con rmed daily abuse4. remarriage and quarrel to force sex upon wives early Similarly, a survey5 among the health professionals in marriage. As a result, for most present generation revealed that domestic violence has been reported to women, married life means depression, mental torture, result in high maternal death, preterm birth and high self immolation; bride burning for dowry demand. prenatal mortality, abortion, miscarriage and impact on long term health of women. In addition to causing Wife battering is covered by Domestic Violence Act injury, violence increases women’s long-term risk of entitled “Legislation to Control and Manage Domestic a number of other health problems, including chronic Violence 2009” in Nepal. The Women’s Rights pain, physical disability, drug and alcohol abuse, and Division of Human Rights Watch ghts against the depression. Backache, problem in vision and poor dehumanization and marginalization of women with subjective health were common physical health solidarity to end traditions, practices, and laws that harm problems. women. Although the Interim Constitution does not allow discrimination based on sex, , creed or colour there Traf cking of girls/women is another gross violation are more than 150 discriminatory provisions against of the human right and a serious form of VAW. The women in the forms of denial access to and control over traf cking of girls/women from Nepal into India and resources, restricted mobility, low representation in Middle East takes place mainly for the purpose of decision-making positions in civil services, politics and prostitution. Traf cking in women and girls is easy public sectors, lack of opportunities for advancement along the 1,740 mile-long open border between India and the attendant problems resulting in longer working

89 hours, illiteracy, poor health, high maternal mortality good results. However, in our country post intervention rates, increasing number of traf cking of women and studies to measure the reduction in abuse are almost girls, violence against women and girls, witch-hunting lacking. Experiences from other countries shows mixed and so on. In the absence of proper legal protection, results in term of shelter effectiveness, less physical re- many widows and women in rural Nepal are often abuse, improved quality of life, increased use of social accused of practicing witchcraft, beaten, paraded naked support, increased effectiveness in obtaining resources7. and forced to eat excreta by illiterate and superstitious We should also think about potential harms that might villagers. As we have no speci c law to deal with such arise from such interventions. For example, involvement evil acts, they are dealt with under the Public Offense of child protection agency or women rights groups in Act, and the District Administration Of ces let off the business may put the children and women at greater perpetrators of such crimes after imposing some nes. risk from the abuser. Sometime there is reprisal of abuse We hope the new Constitution of Republic of Nepal will against those women who return home from shelters, be able to encompass the lacking issues in the previous and to prevent that structured post-shelter advocacy constitution. counselling is effective in reducing re-abuse. VAW is a complex issue and needs attention from wide range In Nepal, health care providers are still likely to be the of authorities. The role of clinicians is also complex, rst point of contact between a woman in dif culty and starting from the screening of the problem until the long the formal health care system, and as such constitute term rehabilitation. At the end, I would like to state a fact a frontline of identi cation and intervention. Usually, that there is insuf cient evidence to recommend for or such women present at the hospital or clinics with other against routine universal screening for violence against somatic problems, and try not to mention about violence. either pregnant or non-pregnant women, however Providing a supportive, violence-aware practice clinicians should be alert to signs and symptoms of environment, using sympathetic and empowering potential abuse and may wish to ask about exposure to language that is appropriate to each patient, knowing how abuse during diagnostic evaluation of these patients8. to conduct a physical examination to con rm physical / , and being aware of local services to which References women who are abused can be referred as an important 1. UNC Fund. Domestic Violence against Women steps towards its prevention. It is very important that and Girls. Innocenti Digest. 2000; 6. they know how to provide thorough treatments of not 2. Population Council. Violence against Women. only the physical consequences of abuse but also the Population Briefs. 2005; 11( 3). mental health sequel, including post-traumatic stress 3. Pathak LK, Malla D, Pradhan A, Rajlawat R. disorder. The consulting physicians should consider Maternal mortality and morbidity study. Nepal: treatment of the abuse of women as a complex, Family Health Division, Department of Health multidimensional clinical problem and its provision of Services.1998. speci c practical suggestions and resources relevant to the continuum of care, from identi cation to diagnosis, 4. SAATHI. The Situational Analysis of Violence immediate intervention, and long-term management. It against Women and Girls in Nepal. Kathmandu: does not mean that all women who come to health care SAATHI. 1997. settings should be asked about abuse, whether or not 5. Samanata. Linkage between Domestic Violence there are clinical indications of violence. and Pregnancy. Kathmandu: Samanata. 2005. 6. United States Department of State. Traf cking There are many screening tools available for various in Persons Report 2008 - Nepal, 4 June 2008 settings, and for pregnant women. Examples of few such [homepage on the internet]. available at: http:// available tolls are Con ict Tactics Scale (CTS & CTS-2), www.unhcr.org/refworld/docid/484f9a2fc.html Composite Abuse Scale (CAS), Partner Violence Screen 7. Sullivan CM. Bybee DI. Reducing violence (PVS), Index of Spouse Abuse (ISA), Woman Abuse using community-based advocacy for women Screening Tool (WAST), Abuse Assessment Screen with abusive partners. Journal of consulting and (AAS) (for pregnant women). Many doctors use such clinical psychology. 1999; 67(1):43-53. tools reasonably well in identifying women who have 8. Wathen CN, MacMillan HL. Prevention of been abused. If they suspect of abuse, interventions, violence against women: Recommendation such as counselling in the primary care setting, referral statement from the Canadian Task Force of women for expert counselling, referral to a safe place on Preventive Health Care. CMAJ. 2003; or community resources are important. Sometimes, 169(6):582-4. referral of batterers/couples for expert counselling yields

90