Special Articles / Bhavna Mehta / Scientific Writing and Publishing in Social Work
Domestic violence violates women’s human rights. It not only impacts on women’s physical and mental health but also deters women from attaining a healthy life. The present paper establishes triangular relationships among domestic violence, human rights and the mental health of women in the larger context of what profession social work stands for. Reviewing the efforts of social work professionals working in the field of mental health, human rights and/or women’s issues in India, this paper advocates the need to recognize this inseparable nexus existing amongst the three and make social work interventions accordingly.
Women’s rights are human rights and domestic violence (DV) is a human right issue. This was recognized and accepted by the world community almost two decades ago, forty five years after the adoption of the Universal Declaration of Human Rights (UDHR).
Every year, violence in the home especially violence by husband or intimate-partner affects the lives of millions of women globally. It is a universal phenomenon and one of the most common forms of violence against women worldwide. While it differs in its scope from one society to the other, it exists everywhere. Around the world, as many as one in every three women has been beaten, coerced into sex, or abused in some other way – most often by someone she knows, including by her husband or another male family member; one woman in four has been abused during pregnancy (UNFPA website). The WHO (2005), Multi-country study on women’s health and DV in 10 mainly developing countries found that, among women aged 15-49 between 15 percent women in Japan and 71 percent women in Ethiopia reported physical and/or sexual violence by an intimate partner at some point of time in their lives. Thus, it is acknowledged now that violence against women (VAW) is a violation of women’s human rights.
India with the presence of myriad customs, traditions and cultures based on strong patriarchal, discriminatory values and practices, is no exception but a glaring example of a society having high incidences of DV. A review of micro studies shows that 22 to 79 percent of women surveyed in different parts of the country have experienced DV. According to National Family Health Survey (2007), nearly 37 percent of Indian married women between 15-49 years of age have experienced DV.
VAW be it in any form, affects all aspects of women’s health including their survival. It is also a risk factor for their ill health (WHO, 2002). The adverse impact of violence on women’s health has been acknowledged worldwide in various international covenants, conventions, conferences and declarations (notable among them CEDAW 1992, World Conference on human Rights, 1993, Fourth World Conference on Women, 1995, Beijing + 5 Conference, 2000).
Health is a basic human right. And as large numbers of women are affected by violence against them world over, VAW is now recognized as a crucial human rights as well as public health issue due to the associated health risks of this violence. The 49th World Health Assembly of 1996 and the United Nations Population Fund in 1999 declared VAW as a ‘Public Health Priority’. This stems from a belief that for women’s holistic health, all the factors impinging on their health must be addressed by health system especially when large numbers of women are affected by violence and are of ill health.
Understanding Domestic Violence
DV is the violence that occurs within the private sphere, generally between individuals who are related through intimacy, blood or law. It can include any nature and type of violence taking place within the domestic place called home, household or family. It can be violence against women and girls of the family, violence between siblings, on child/children, elders of the family. But, DV is usually used to describe the act of violence committed by men against women in intimate relationships or by husband and his family members on the wife.
This is because police and hospital records globally have indicated that the majority of victims of DV are women. Even experiences of women’s organizations, voluntary organizations working with women reflect that women are abused, harassed, tortured, coerced by their own partners or husbands, and marital family members within their own homes. (UNFPA, 2003).
The British Council (1999) defines DV based on the concept of gender violence given by the United Nations General Assembly while formulating the CEDAW declaration in 1993. It defines DV as all such gender based violence and abuse taking place on women in adult marital relationships.
In India until recently, the laws, public discourse and media had equated DV with dowry violence (Violence on woman by her husband or in laws due to their demand/expectation of gifts, money, goods or property from woman’s family before, during or any time after marriage). It was only in 2005 that the newly enacted legislation of the country titled Protection of Women from Domestic Violence Act, 2005 considered physical, psychological and sexual abuse confronted by women daily in her marital relationships for any reason or without reason as DV.
Thus, now the term DV has almost become a synonym for violence against married women or violence by intimate partner taking place within the four walls of the home, within the family.
Perspectives on Domestic Violence
The issue of DV has been viewed and understood from different perspectives. A few of the common perspectives that have dominated different societies’ views and their responses to DV historically include the traditional perspective, the socio-legal perspective and the feminist perspective.
The traditional perspective views DV as a justifiable act, a ‘rightful act’ on the part of the husband. It is considered as a private affair, an intra-familial issue that is a sanctioned and an accepted evil of the society.
The socio-legal perspective views DV as a social problem affecting the quality of life of many women, children and families. It accepts that DV has serious social, economic consequences at individual, familial and societal levels. While also a crime perpetrated against women by men/husbands and their family members.
Feminists view violence as a means used by men to control women. Its roots are seen in the unequal balance of power between men and women found highly in patriarchal family and society set ups. Feminists believe that violence is not a private, family matter but a social one (Personal is Political). They believe in understanding violence from the experiences of women’s own frame of reference and view women who have experienced violence as “survivors” who have many adaptive capacities and strengths.
Domestic Violence - A Human Right Issue
Though it was only after the World Conference on Human Rights, 1993 that VAW especially DV was recognized formally as a human right violation, the right to life and bodily integrity are the core fundamental rights that existed under Universal Declaration of Human Rights since 1948. DV, considered as ‘private affair’ was not recognized earlier as human rights violations because traditionally it was believed that international human rights laws do not apply to ‘private harm’. Similarly, international legal institutions then had restrictive interpretations of the State responsibilities. As per this view, human rights norms governed the conduct of the States, and States were responsible for the violations they perpetrated however, DV occurring in private spheres called homes was seen as outside the peripheral of the State’s responsibilities.
Over time, the notion of state responsibility under international law has been expanded in number of ways. It is now recognized that human rights laws apply to ‘private conduct’ such as DV. As Radhika Coomaraswamy, United Nations Special Rapporteur on VAW explains, there are three ways in which DV can be understood as human rights violations: due diligence, equal protection and torture.
First, as articulated by the Committee on the Elimination of Discrimination Against Women in General Recommendation 19, States are not only obligated to refrain from committing violations themselves, but are also responsible for otherwise “private” acts if they fail to fulfill their duty to prevent and punish such acts. This responsibility is reflected, as well, in the Declaration on the Elimination of Violence against Women and the Vienna Declaration and Program of Action from the 1993 World Conference on Human Rights. Consequently, when the State fails to ensure that its criminal and civil laws adequately protect women and consistently hold abusers accountable, or that its agents—such as police and prosecutors—implement the laws that protect victims of DV, it has not acted with due diligence to prevent, investigate and punish violations of women’s rights.
Second, States are required under international law to provide all citizens with equal protection of the law. If a State fails to provide individuals who are harmed by an intimate partner with the same protections it provides to those harmed by strangers, it has failed to live up to this obligation. When law enforcement officers respond quickly to reports of stranger violence but fail to respond to reports of intimate partner violence, when forensic medical classifications allow accurate evaluations of the severity of injuries inflicted by strangers but consistently fail to reflect the seriousness of the kinds of injuries inflicted in an abusive relationship over time, when judges impose lower sentences on those who assault strangers than those who assault their intimate partners—battered women have been denied equal protection.
Third, advocates and scholars increasingly recognize that DV is a form of torture. Under international human rights law, torture is severe mental or physical pain or suffering that is intentionally inflicted either by a State actor or with the consent or acquiescence of a State actor for an unlawful purpose. According to Coomaraswamy, the dynamics of DV closely resemble the defining elements of torture: “(a) it causes severe physical and or mental pain; it is (b) intentionally inflicted, (c) for specified purposes and (d) with some form of official involvement, whether active or passive.” (Coomaraswamy, 2000). The similarities between these violations are striking particularly because DV and torture are often perpetrated for the same unlawful purpose—namely, to establish and maintain power and control over another.
Thus, the human rights perspective considers VAW as an act against the fundamental notion of humanity, eroding women’s sense of being human, viewing women’s rights as human rights and VAW as a violation of women’s human rights. Moreover, it believes that the State and its agencies (social, political, legal, health, etc.) have an obligation to protect, support and help women victims of violence. Failure of the State and its agencies to carry out any obligations (action or omission) that violates women’s human rights against violence is also seen as the one inflicting further VAW. This perspective strongly believes that it is the responsibility of the State to ensure that victims of DV are afforded the same legal protections that are available to all victims of any other type of violence.
In India, the specially enacted legislation on DV, titled Protection of Women from Domestic Violence Act, 2005 defines DV not only from the human rights perspective but also recognizes that any act by family members which harm women either physically or mentally be considered as an act of DV.
Understanding Women’s Holistic Health as a Right
Health has evolved over the centuries as a concept of individual concern (absence of disease) to wellbeing of individuals and society determining social development (Bajpai, 1998) to a powerful tool for women’s empowerment (Batliwala, 1993) or as relative to the aspirations of individual or groups thus defined in relation to the users’ perspective. It has also evolved from being a welfare concern to a fundamental human right encompassing the whole quality of life and a worldwide social goal. It is not mainly an issue of doctors, social service and hospitals but an issue of social justice.
In this context, women’s health must be defined holistically so that it encompasses all the determinants affecting their health. A holistic view of women’s health recognizes that biological, psychological, social-cultural, economic, violence and life style issues affect women differently than men, and that women require specialized services and care. The holistic approach strives to address all aspects of women’s health and all sources of ill-health across their entire life cycle. It believes that if concerns related to each stage of women’s lives are addressed distinctively, women’s overall health and well-being will improve.
The holistic health approach also recognizes that women and men are human beings with full and equal human rights. The general comment No.14 on Article 12 of the International Covenant on Economic, Social and Cultural Rights recognizes women’s human right to health and elaborates it to include “the right of everyone both men and women to the enjoyment of the highest attainable standard of physical and mental health.” (CESCR, 2000) This definition acknowledges that women’s rights to health include a wide range of socioeconomic factors that promote conditions in which people can lead a healthy life. It extends the understanding of health to its underlying determinants including violence.
While human rights perspectives sees DV as violation of women’s rights to life, bodily integrity, equality, dignity and security, the holistic health perspective looks at VAW as an impacting factor affecting and determining women’s overall health.
Impact of Domestic Violence on Women’s Health
DV is called ‘hidden epidemic’ because it is widely prevalent in the privacy of the home. The consequences of any abuse, violence on anybody can be profound, extending beyond the health and happiness of individuals to affect the well-being of entire communities/society. In the case of women, these consequences are graver, consequentially because of their disadvantaged position in the society. A growing body of research that has emerged in recent years across the world reveals that DV is detrimental to women’s health including their very survival. The impact that DV has on women’s health can be both immediate and/or long term, fatal and/or non-fatal, direct and/or indirect.
Dillion, Gina and others reviewed 75 quantitative and qualitative research studies on mental and physical health and intimate partner violence published between the year 2006 to 2012 from western and developing countries. They found that there was variation in prevalence of DV or intimate partner violence across various cultural settings and DV was associated with a range of mental health issues including depression, PTSD, anxiety, self-harm and sleep disorders. The review also found that DV was also associated with poor physical health including poor functional health, somatic disorders, chronic disorders and chronic pain, gynecological problems and increased risk of STIs and HIV (Dillion, G. & et.al., 2013). Based on the available scientific literature Lorie Heise, Jacqueline Pitanguy and Adrienne Germain (1994) summarized the health consequences that have been associated with DV. According to them fatal outcomes of DV include homicide, suicide, maternal mortality, AIDS related health outcomes; and non-fatal outcomes include but not limited to physical health problems like injury, functional impairment, physical symptoms, poor subjective health, severe obesity, permanent disability; chronic conditions issues like chronic pain syndrome, irritable bowel syndrome, gastro intestinal disorders, somatic complaints, fibromyalgia, asthma,; negative health behavior like smoking, alcohol and drug abuse, sexual risk taking, physical inactivity, overeating; reproductive health issues like unwanted pregnancy, STIs/HIV, gynecological disorders, unsafe abortion, pregnancy complications, miscarriage/low birth weight, pelvic inflammatory disease and mental health of women.
Domestic Violence and its Impact on Women’s Mental Health
The impact DV has on women’s mental health is more severe than the impact it has on any other aspects of women’s health. The psychological damage caused by violence lasts longer or sometimes forever. Experience of violence affects women’s self-esteem and makes them more vulnerable (puts them at greater risk of) to a variety of mental health problems including depression anxiety, post-traumatic stress disorder(PTSD), suicide, suicide attempts phobia/panic disorder, eating disorders, self-harming behavior, sexual dysfunction, low self-esteem and substance abuse.
The review of available Indian studies on the effects of DV on women’s health (Mehta, 2007) and the work of Lorie Heise and others (1994) indicate that DV has an enormous impact on women’s physical, reproductive and mental health. While physical or reproductive health consequences are visible, the impact of different forms of violence on women’s mental health, leaves scares on her feelings, hopes, marriage aspirations and a hope for a life entirely her own. These impacts cannot be seen, measured or easily accounted for (Mehta, Desai and Desai, 2000).
The review of 41 worldwide studies by Trevillion, Oram, Howard (2012) finds that women with symptoms of depression were 2.5 times more likely to have experienced DV over their lifetimes than those in the general population while those with anxiety disorders were more than 3.5 times more likely to have suffered domestic abuse. The extra risk grew to 7 times more likely among those with PTSD.
A Brazilian population based household survey of women aged between 15-49 years found that the prevalence of mental disorders was 49 percent higher among women who reported any type of violence compared to 19.6 percent among those who did not report any violence. The first national study of 2000 adult women in Norway found that exposure to partner violence is associated with depressive and PTSD symptoms as well as a range of somatic problems clinical studies conducted in Italian, Australian, European, US primary health care settings have found that female patients experiencing DV are more likely to be depressed than women not experiencing violence (cited in Howard et. al., 2010).
Examining other literature related to impact of DV especially on women’s mental health, it is found that abused women are five times more likely to attempt suicide and one third of all female suicide attempts can be attributed to current or past experiences of DV (Stark and Flitcraft, 1996). Department of Health, London (2003) found that 70 percent of women psychiatric in patients in their hospitals have histories of physical and sexual abuse. Whereas other studies of ReSisters (2002) and Bowstead (2000) report that 50 and 60 percent of women mental health service users has experienced DV. In a study of DV in Chiapas, Mexico, women identified numbers of psychological consequences like feeling angry, ill at ease, suffering, repulsion towards violent mass and lack of sexual pleasure as most frequent whereas sadness, fear, mental trauma, nervousness and anxiety, disappointment, worry, despair and regret as less frequent psychological consequences of DV (Glantz and Halperin, 1996).
While there are very few Indian studies that have examined impact of DV/intimate partner violence on women’s mental health, the recent study of women presenting to an adult psychiatry out patients unit of a mental health institute of South India undertaken by Chandra, P and others (2009) found that 56 percent of the women patients reported the history of DV/intimate partner violence of whom 70 percent also reported sexual coercion. Among women who reported of experiencing DV, 14 percent exceeded the cut off scores of PTSD whereas 20 percent exceeded cut off scores for sub-threshold PTSD. The majority of those experiencing violence exceeded also on cut off scores for depressive disorder. Severity of violence and sexual coercion correlated positively with PTSD severity. The first Indian study (unpublished dissertation) on DV among female psychiatry patients visiting the psychiatry department of the civil hospital in Gujarat indicated that the vast majority of psychiatry patients (88 percent) had experienced at least one type of abuse and one third (38 percent) of respondents had experienced physical, sexual as well as psychological violence. For majority of women, experiences of violence were not isolated single experiences (Mehtalia, 2004).
In an another study of Five Government Hospitals of Gujarat in India, 60 percent of women with mental health problems mentioned DV as one of the causes of their mental health problem. The study also found that health care professionals observed a variety of mental health problems amongst survivors of DV including suicide, suicide attempts, depression and other mental health problems (Mehta, 2007). A small study undertaken in the city of Vadodara in the state of Gujarat, India found that women experiencing DV mainly feel miserable, feel like ending their lives after the episodes of violence as well as feel frustrated/tensed/depressed with a sense of helplessness (Mehta, Desai and Desai, 2000).
Few of the Indian studies on the response of health care providers to DV indicate that health care providers, though aware of the issue, hesitate to (or rather do not) respond to it in their work and that mental health professionals tend to underestimate the proportion of their clients who experience DV as they perceive it as a social/personal problem and diagnosed mental health problem as a sign of mental dysfunction rather than a fall out of violence experienced by them. As a result mental health practitioners ‘just addressed the symptoms’ (Purewal and Ganesh, 2000; Ganatra, cited in Gopal, 2000).
Thus, DV exacerbates existing conditions of women’s mental illness as stigmatization, labeling of being mentally ill coupled with social isolation further increases women’s vulnerability to DV. Moreover, mental health diagnosis may be used against woman in civil and criminal proceedings leading to more and more victimization!
Mental Health and Human Rights of Women in India
As per UDHR, 1948 there are number of obligations that a State has to fulfill in order to meet the mental health needs and to protect human rights of women. These include States’ duty to respect, protect, assist and fulfill. The failure of the State to fulfill any of the obligations and duties in relation to women’s health needs in general and mental health needs in particular would amount to violation of women’s human rights and as a result lead them to further at risk of experiencing DV.
In India, the government has recognized VAW as one of the eleven areas of concern in its 1995 country report, for the Fourth World Conference on Women. It has ratified various international conventions mentioned above thereby guaranteeing women of India protection / support against any form of violence and evolving different measures mechanisms to address the issue at all levels. But at the field level it is found that State intervention has continued to view the issue of DV as a crime, rather than a social problem needing a combined Welfare, Police and Judicial response (Mitra, 2000; Poonacha and Pandey, 2000). Government health care programmes are far from addressing the issue from human rights perspective in general and public health perspective in particular. DV has neither assumed any importance as a public health issue nor does it even warrant any mention in the core areas of work of the health care delivery system of the country till today. However, the most recent development with the union cabinet of the country clearing a right based Mental Health Care Bill, 2013, there is a ray of hope that all those striving to improve the mental health of women of the country would not only look at mental health needs of women as their rights but would also address the issue of DV as their important agenda.
Domestic Violence, Mental Health and Human Rights –An Inseparable Triangular Challenge for Social Work in India
The social work profession promotes social change, problem solving in human relationships and the empowerment and liberation of people to enhance the well-being of individuals and society. Principles of human rights and social justice are fundamentals to social work (IFSW and IASSW, 2004). And as Gandhi (2001) put it “DV threatens to nullify all what social work stands for i.e. human dignity, self-worth, social justice, human rights and empowerment”. Thus, it is imperative that social work professionals working on the issue of DV, mental health and human rights understand the importance of addressing the mental health needs of women affected by DV and view DV and unmet mental health needs of women as a violation of women’s human rights.
Unfortunately in India, there are very few social workers working in the field of health including mental health. And those who are in the field do not /cannot address the issue holistically due to varied reasons like lack of perspective, clinical approach, work pressures, institutional constraints and self-view on DV (Mehta,2007; Verma and Khanna, 2000) Similarly those who work on human rights issues address the issue of DV from legal justice point of view. There are social workers who have started recognizing the link between DV, mental health and human rights and have begun to address the issue with a holistic perspective. But such initiatives are very few. e.g. ‘Dilaasa’, WCH project of BMC in Mumbai, Masum in Pune.
There is a need to introduce social work intervention programs promoting women’s holistic health from a human rights perspective. Similarly, health care systems of the country need to not only introduce screening of women experiencing DV in all its settings but also set up Crisis centers with social workers to ensure that women screened out as survivors of DV are referred for necessary help and support. Moreover, mental health teaching, training and service programs of the country must include DV as an important cause requiring mental health professionals’ attention for the overall mental health of the society.
DV is a difficult and intractable health and social problem of our society demanding socio as well as medico interventions. At the same time, no highest attainable standard of health is possible for women unless the impact DV has on women’s health including women’s mental health is recognized and their health needs are addressed. Moreover the goal of social justice is not possible to attain in a society where women’s human rights are violated due to the failure of the State to protect women from DV and fulfill physical, psychological and reproductive health needs of women arising out of DV.
In India, it is required that social workers working on women’s issues, health issues and human rights issues recognize the triad relationship between these three concepts and work with women accordingly, partner with government so as to introduce policy and program change. This would be possible when the institutions imparting social work education build this perspective into the future generation of social workers through their teaching and training programs.
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