In the crowded emergency ward of a hospital, Dr Prabhat Rijal met a patient covered in bruises.
Her visit was expected. The doctors at Rapti Sub-Regional Hospital in Ghorari, western Nepal see at least one case like this a night. It’s usually shortly after dusk, when abusive men come home from work and start drinking. The patients tend to come in gripping their stomachs or complaining of earaches, but the nurses and doctors look out for bruises or cuts on their bodies that suggest a different story.
Rijal, suspecting something was off, asked the woman what happened. She had run out of her house after her husband beat her, the patient said. Her hair was still slick with sweat.
The team at the crisis management centre – staff nurse Punam Rawat, counsellor Radha Paudel and police officer Sabita Thapa – listens to a patient (Credit: Bunu Dhungana)
The dimly lit emergency ward is busy late into the night, with children running around and patients on every gurney, so Rijal and a nurse led the woman into a private room and shut the door. They followed the script they normally employ. Abuse is not normal or inevitable, they told her. She has options.
Moments later, the nurse led her to the one-stop crisis centre, a separate wing of the hospital where patients facing abuse can meet counselors and a female police officer.
The one-stop crisis management centre at Rapti Sub-Regional Hospital in Ghorahi, Nepal (Credit: Bunu Dhungana)
Intimate partner violence often leads to long-term health problems. And a doctor’s office is usually the first – if not the only – place where someone might not only notice the problem, but have the expertise and authority to help.
Many governments don't prioritise intervention in healthcare settings
Many governments don't prioritise intervention in healthcare settings. But Nepal, which has some of the highest levels of domestic abuse, is among a growing number of countries embracing a health response – placing support services inside hospitals and training providers to identify and refer abused patients.
‘As common as asthma and diabetes’
Worldwide, almost one-third of women who have been in a relationship report having experienced physical or sexual violence from their partner. Intimate partner violence is exacerbated in countries experiencing or recovering from conflict, like the Democratic Republic of the Congo and northern Uganda. Although attitudes are changing, studies suggest it is also more accepted in countries across Asia, Africa, and Oceania
In the US, 32% of women have experienced physical partner violence and 16% have experienced sexual violence from a partner
It isn’t only the developing world. A third of women in Denmark and just under 30% in the United Kingdom report having experienced intimate partner violence at least once in their lifetime, for example, with around 5% reporting an occurrence in the last 12 months. In the US, 32% of women have experienced physical partner violence and 16% have experienced sexual violence from a partner, with almost 4% experiencing physical violence and 2% experiencing sexual violence in the last year.
The impact violence has on women’s health is immense.
In the US, intimate partner violence results in 2 million injuries each year, making it a larger health problem than obesity and smoking. It is associated with chronic pain, asthma, difficulty sleeping, irritable bowel syndrome, heart disease, diabetes, stroke and sexually transmitted diseases. Women who have experienced violence from a partner are at higher risk for suicide and more likely to suffer from depression, anxiety, panic attacks and post-traumatic stress disorder.
Since 40% of female homicide victims are killed by their intimate partners, intervening at this stage can save lives
Medical workers are often the first service responders to come in contact with people experiencing abuse: in the US, for example, women in abusive relationships visit health centres 2.5 times as often as other patients.
Sabita (not her real name) visits the one-stop crisis centre for follow-up counselling once a month (Credit: Bunu Dhungana)
Since 40% of female homicide victims are killed by their intimate partners, intervening at this stage can save lives. One study of 139 female homicides that took place over five years in Kansas City found that nearly one-quarter of homicides – 34 – were related to domestic violence. And 15 women had presented to an emergency department – 14 of them with injuries – within the two years before they were killed. A recent survey of 1,554 victims attended to by police after domestic violence calls found that 88% reported having survived a previous strangulation attempt.
But health providers are often unprepared to help patients. In Britain, a 2017 study found that most medical trainings don’t adequately cover intimate partner violence. Although the Affordable Care Act in the United States mandates that more insurance plans cover screening and counselling for patients facing violence, the US government still doesn’t have a national protocol.
Counsellor Radha Paudel stands in front of the room where she meets with patients (Credit: Bunu Dhungana)
Training medical workers to identify and refer abused patients depends on how a country funds its healthcare, says Kelsey Hegarty, a family physician and researcher who helps develop health interventions in Australia. Governments can’t require privately funded institutions train their staff on responding to intimate-partner violence and many governments don’t fund protocols and trainings. As a result, civil society groups often take on the task of developing interventions and in-hospital services.
“For something that is as common as asthma and diabetes and causes ill health, it’s very disturbing,” says Hegarty.
Not sensitising health providers has consequences. One recent study suggested that some health providers in Lebanon feel violence is justified if women exhibit aggressive behavior.
Unsurprisingly, patients often don’t feel comfortable disclosing abuse. In Nepal – where nearly half of women have experienced some form of abuse – patients worry that health providers will laugh at them or accuse them of not being “good” wives.
The police didn’t even care when I told them what happened to me before, so why would doctors care? – Neha
“The police didn’t even care when I told them what happened to me before, so why would doctors care?” says Neha, who had been in an abusive marriage before she visited a one-stop crisis centre in Nepal. (To protect the safety of the women interviewed, we have not used real names.)
Neha, 38, waits outside a shelter home and knitting centre for survivors of intimate partner violence (Credit: Bunu Dhungana)
There is debate over how health providers should identify patients like Neha. Some advocates recommend screenings which require that health providers ask patients if they’ve faced abuse. But there’s little evidence to suggest it helps. A review of 11 studies in the British Medical Journal found that screenings helped identify patients facing abuse, but did not necessarily help them access support services. The World Health Organization advises against screenings in its guidelines on gender-based violence for health providers.
Instead, many experts suggest approaches like the one Nepal has embraced.
Inside the one-stop crisis centre at the hospital in Ghorahi, Maya was curled up on a teal-covered cot. She had visited the emergency ward a day before. Now, she was back to meet with counsellor Radha Paudel, who sat crouched near her bed, inspecting a string of bruises running up her arm. On a pillow nearby was a sheet of paper listing her other symptoms – a headache, hematoma in her right hand, swelling on her head, pain in her chest and on her upper and lower back.
“You came in earlier with your husband, too,” Radha said in a near-whisper.
“My husband refused to come today,” Maya said. He was at her house watching her children.
Maya, 34, waits in the examination room inside the one-stop crisis centre with her mother and neighbour (Credit: Bunu Dhungana)
Months earlier, Maya had lodged a complaint against her husband, who was briefly arrested, and filed for divorce with the help of Sabita Thapa, the police officer who works at the crisis centre full-time. Radha connected Maya with a local women’s group to help her establish an independent source of income. Her situation reflects an imperfect, but evolving health response. Although Maya still faced abuse, the one-stop crisis centre has linked her to multiple services. Her husband has moved out and their divorce is pending in court.
Nepal opened its first one-stop crisis centre in 2011 in its central and far-western regions and continues to place them in hospitals around the country. In 2015, the government developed a protocol to help health providers identify and refer more patients to the crisis centres, which received technical support from Jhpiego and the UN Population Fund and is now funded by the government.
Hundreds of health providers have been trained so far, ranging from gynaecologists to family physicians at small health posts high in the Himalayas.
In 2013, only 74 women reported abuse to the hospital. By 2017 that figure jumped to 493 women
At the hospital in Ghorahi, experts believe this multi-faceted approach has helped increase the number of women reporting abuse and receiving counselling and legal advice. In 2013, only 74 women reported abuse to the hospital. By 2017 that figure jumped to 493 women. Although most women visited the hospital to report abuse on their own, each year the number of nurses or doctors referring patients to counsellors increases.
“Health workers were scared handling these types of cases,” says Saroja Pande, one of the physicians who helped design the protocol. “They would refer them to services, but the survivors were traumatised and would drop out of follow-ups, stay at home and develop depression. Some killed themselves.”
Today’s trainings are comprehensive. They include a mix of theory, games and role-play scenarios, including a courtroom simulation to prepare health providers for what will happen if they are called to present evidence.
Dr Prabhat Rijal meets a patient in the outpatient department; he regularly identifies intimate partner violence cases and refers them to the crisis centre (Credit: Bunu Dhungana)
Another goal is to expand empathy. Medical workers are encouraged to recognise and question biases they may hold about abuse. During one session, the trainers ask them if they believe a woman wearing a short skirt is assaulted because of her clothing choice. They take the opportunity to debunk myths about what motivates abusers.
We tell health providers, if you can’t serve a survivor from the bottom of your heart, then don’t touch their case – Ishwor Prasad Upadhyaya
Ishwor Prasad Upadhyaya, the training coordinator, says they want health providers to think of this work as more than a job. “We tell them, if you can’t serve a survivor from the bottom of your heart, then don’t touch their case,” he says.
“If you can’t serve them, send them to another health worker.”
Other countries have similar approaches. One-stop crisis models and their variants exist at health centres in Rwanda, Guatemala, India, England, Malaysia, South Africa and Colombia, among others. Jordan’s government has a protocol for health providers and reproductive health clinics, like Profamilia in the Dominican Republic, screen patients for gender-based violence.
But these approaches still face serious challenges. Experts agree that merely training health providers is not enough unless a country has strong support services in place, including shelters. But in Nepal, as in many countries, shelters are underfunded, only let domestic abuse survivors stay for a brief period of time, and can be rare in rural areas.
The counselling room inside the one-stop crisis centre (Credit: Bunu Dhungana)
At the hospital in Ghorahi, there can be delays in following up with patients, which may make them less likely to seek support services. Many women also opt for family counselling instead of filing police complaints against their husbands, owing to a lack of family and financial support. Police officers in Nepal often urge mediation as an alternative to prosecution, but research in the United States suggests it can increase risk.
Worldwide, the burnout rate for health providers engaged in this work is also high, says Upala Devi, the gender-based violence coordinator of UNFPA.
“I think what we’re seeing right now in terms of momentum is very positive and welcome,” she says. “But at the same time much more remains to be done.”
How untrained health providers can help
Experts agree that health providers who haven’t been trained can still help identify and refer abused patients.
Hegarty has only one piece of advice: read the World Health Organization’s guidelines on responding to gender-based violence, which outline evidence-based suggestions.
Most importantly, the guidelines list the things a health provider should consider before asking a patient if they face abuse – such as make sure you are in a private setting, ensure confidentiality, follow a protocol, and refer him or her to resources, including legal and other support services.
Ideally, health providers should be trained on how to sensitively ask about abuse. But in situations where this isn’t possible, the guidelines explain how to listen, enquire about needs, and validate the patient’s experiences.
If a patient seems depressed or answers questions erratically, a health provider should consider asking them about their relationships
In Nepal, health providers keep an eye out for patients who come in with vague symptoms or symptoms that don’t correspond with an examination’s physical findings. They also observe their behaviour and that of those accompanying them. If a patient seems depressed or answers questions erratically, a health provider should consider asking them about their relationships or refer them to a qualified counselor, says Pande. If the family member or spouse accompanying the patient refuses to leave her alone with a health provider, this might also signal abuse.
Jinan Usta, a physician who has designed training for health providers in Lebanon, says it’s important to develop safety plans with patients if they choose to stay with their abusers. First, medical providers should ask the patient whether the violence has increased over time or in severity, and if there are firearms or other sharp instruments around. If there are, she recommends patients leave the house immediately when their abuser starts acting violently.
There are a number of other safety measures: avoid hiding in enclosed spaces, have a number on your mobile phone of someone you can call immediately, hide sharp instruments, and keep the front door of your home unlocked so that you can quickly exit.
Usta believes that listening to domestic abuse survivors holds its own power. “It’s enough to listen to the women and make them feel like they are not alone in this,” she says.
Three years ago, Sabita reported abuse here; she regularly refers other women to the centre now (Credit: Bunu Dhungana)
Sabita agrees. On a recent afternoon, she walked into the crisis centre in Ghorahi during a burst of monsoon rain and sat in a corner, watching the staff shuffle papers.
Three years ago, she reported abuse here. Now she stops by for follow-up counselling. She has moved back in with her husband, but says the abuse stopped shortly after the crisis centre staff helped organise his treatment for depression. She regularly refers other women to the crisis centre.
“They treat us better than our mothers and fathers,” she says.
If you have experienced gender-based violence or know someone who you believe has, you can consult the UN Women’s Global Database on Violence Against Women to find a support hotline in your country.
Those who have experienced or witnessed gender-based violence in Nepal can call 1145, a 24-hour toll free helpline run by the National Women Commission that offers psyco-social support, legal aid, and shelter information.
This story is part of the Health Gap, a special series about how men and women experience the medical system – and their own health – in starkly different ways. Do you have an experience to share? Or are you just interested in sharing information about women's health and wellbeing? Join our Facebook group Future Woman and be a part of the conversation about the day-to-day issues that affect women’s lives.
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