INTRODUCTION
The word gender is included in gender-based violence (GBV) because violence is generally targeted at women as they are a vulnerable group in general all over the world. Women face violence in all aspects of life, starting from prebirth in the form of sex-selective abortions and continue fighting it till an elderly age.1
In a developing country like Nepal, abuse is taken as a personal matter and women do not mention violence unless asked directly; therefore, health-seeking behavior is extremely rare. A reproductive health facility may be the only place where a woman comes for a health visit. So, health care providers, especially gynecologists, play an important role to identify women suffering from GBV as they see clients suffering from the reproductive health effects of the GBV on a daily basis. Therefore, a Gynecology Outpatient Department (OPD) may be an entry point where such women can be identified timely.
The purpose of this study was to find the prevalence of GBV in women attending the OPD and to identify the gynecology problems they present with.
MATERIALS AND METHODS
This is an analytical cross-sectional study, conducted at Lumbini Medical College Teaching Hospital for a period of 3 months (August 1 to October 31, 2016) after the approval from the Institutional Review Committee.
The total number of women presenting at gynecology OPD of the hospital were noted. All nonpregnant women who gave consent to participate were included in the study. These women then underwent complete history taking and general and physical examination, and the findings were recorded in a predesigned form. The clinical diagnosis was made and noted.
These women were then taken for an interview to a private room ensuring privacy and confidentiality and a structured questionnaire was filled after an informed consent was taken. Women were free to withdraw from the study if they were uncomfortable during the interview. Since the interview was taken by two interviewers, women attending OPD 3 days a week (Monday, Wednesday, and Friday) were only included in the study.
The questionnaire was based on NorVold Abuse Questionnaire (NorAQ), which is a validated tool for assessment of abuse.2 This tool was translated to Nepali and pretested in this population.
Those women identified suffering from GBV were informed about avenues of help seeking, and further referral was done based on the final decision of the patient. For those with obvious psychiatric manifestation, psychiatric consultation was done.
Data were analyzed using Statistical Package for the Social Sciences version 21.0. Comparison of categorical variables was done using Chi-square test. Differences were regarded as statistically significant at p < 0.05.
RESULTS
There were a total of 814 nonpregnant women attending gynecology OPD on 3 days a week during the study period.
Of the 814 women, 746 women gave consent to participate in the study. Five women withdrew from the study during the interview, so total respondents were 741 (91.03%).
Among the respondents, 172 women suffered from GBV; therefore, the prevalence of GBV among respondents was 23.21%.
The demographic details of the respondents experiencing GBV are given in Table 1.
Emotional and physical violence were the most common type of violence reported by the respondents, followed by emotional violence alone. The severity of each type of violence reported is shown in Table 2.
The contraceptive prevalence among GBV sufferers was 21.51%, and 107 (62.20%) women did not talk about it with anyone. Among those who did, the people who they confided to were mothers [26 (40%)], friends [14 (21.54%)], sisters [20 (30.76%)], neighbors and others [5 (7.70%)].
Most common perpetrators were husbands in 154 (89.53%) women. Respondents also reported abuse by mother-in-law [11(6.40%)], father-in-law [3(1.74%)], other family members [2 (1.12%)], neighbors and others [2 (1.12%)].
Home [166 (96.51%)] was the most common site of violence and the causes of abuse were misunderstanding [73 (42.44%)] and alcohol [75 (43.6%)], followed by extramarital affairs [16 (9.3%)], others [8 (4.66%)]. Majority (52.33%) of the women had three or more children.
Clinical profile and clinical diagnosis of the women reporting GBV is shown in Tables 3 and 4.
Table 1: Demographic details of women experiencing GBV
Table 2: Type, severity, and frequency of violence faced by women
Table 3: Clinical profile of women facing GBV
DISCUSSION
Incidence
Gender-based violence is a universal phenomenon and is considered a public health problem that negatively affects health and happiness of a woman. The prevalence of GBV in this study is 23.21%, which is lower than the reported lifetime prevalence of 47% in Nepal.3
In a study by Chaudhary et al4 at Kathmandu, the reported incidence of GBV among pregnant women was 33%, where there was underreporting because <60% women meeting the inclusion criteria agreed to participate. The prevalence is lower in this study even when 91.03% women meeting the inclusion criteria participated in the study.
Type of Violence
One in every three women face GBV in the world irrespective of age, caste, religion, or nationality.5 In a study done in five Nordic countries, lifetime prevalence of GBV was 38 to 66% for physical abuse, 19 to 37% for emotional abuse, and 17 to 33% for sexual abuse.6
The incidence of emotional abuse is 30.23% in this study, which is the same as 19 to 37% reported in five Nordic countries.6 Emotional abuse alone, along with physical and sexual abuse, was found in 68.03%, which is lower than 80% reported as per the national demographic data of Nepal.3 This study was done among women attending specialty OPD in a hospital, so the low rate compared with the national data could be explained by the fact that women facing emotional abuse might not report to a gynecologist.
Physical abuse was faced by 23.83% in this study, which is lower than that reported in other studies in Nordic countries (38 to 66%) and South Asian countries. Studies have reported that 60% women in Sri Lanka and 33 to 75% women in India are hit by a partner.7 National demography shows 31% prevalence of physical abuse in Nepal.3 The prevalence of both physical and emotional abuse is 32.56%, which is in agreement with these studies.
The prevalence of sexual abuse is 8.14%, which is lower than 12% in the national report.3 This implies that talking about sexual abuse even with a health personnel is still considered a taboo by these women. The reported low rate also raises an issue of awareness of sexual violence within marriage among these women if they are not aware of this type of violence, so there will be underreporting of cases. In a study by Puri et al,8 74% women were aware of “sex against one's wishes” as the only mode of sexual abuse by husbands, whereas many other ways of sexual violence within marriage are prevalent in Nepal.
It is not easy to find the prevalence of GBV accurately as women are taught to accept emotional and physical ill-treatment within families as a part of social norm. This will always cause an underestimation of the problem.
Severity and Frequency of Abuse
Majority of the women faced abuse regularly (30.81%) if not daily (23.27%). The study by Chaudhary et al4 reported 41% pregnant women faced abuse daily.
Table 4: Clinical diagnosis of the respondents
Study by Ahmad and Jaleel3 reports that 30.42% women in Nepal face severe abuse by husband. This study shows the severity for emotional, physical, and sexual abuse was 9.61, 7.31, and 57.14% respectively. The severity of sexual abuse is high as women report penetrative sex as abuse but milder forms like genital contact or sexual humiliation might go unreported.
Perpetrators
Partner abuse is the most endemic form of GBV.9 Gender-based violence is prevalent in Nepal, with a patriarchal society, which is the prime basis for the exercise of control over female.10 In this study, majority of women (89.53%) were abused by their husbands followed by mother-in-law in 6.4%. In many countries where large-scale studies have been done, results show that 20 to 67% of women have been abused by the man they live with.5
Gynecological Problems
Violence has an adverse effect on women's physical and psychological well-being and social functioning, thereby limiting their ability to exercise their reproductive rights, leading to grave consequences in the long run.
Sexual abuse victims suffer long-lasting psychological effect, which is often manifested as physical complaints, such as pelvic pain, headaches, asthma, and gynecological problems.9 Violence has been linked to a range of short- and long-term reproductive health problems, such as sexually transmitted diseases, vaginal bleeding, vaginal infections, urinary tract infections, and chronic pelvic pain (CPP).5,11,12
The commonest complaint that abused women presented with was pain abdomen (40.12%), followed by backache (26.16%) and vaginal discharge (15.12). In a study done in teaching hospitals in Gujarat, India, among women attending gynecology OPD, the most common symptom reported was vaginal discharge (98%), followed by lower abdominal pain (76%).13
A study by Jamieson14 with the exception of dysmenorrhea showed that all pain complaints were more common in women reporting abuse both as children and as adults. In this study, there were more women presenting with pain rather than vaginal discharge.
Violence increases the risk of gynecological problems, among which CPP is one common entity. The incidence of CPP is reported as 20% of women attending secondary care hospitals.15 This study showed the incidence of 34.89% among GBV sufferers, whereas it was 9.13% among nonsufferers. Rapkin et al16 also reported 39% of patients with CPP had been physically abused in childhood. Various studies have found that women suffering from CPP are consistently more likely to have a history of childhood abuse of all types.17-19 The findings of this study also prove that CPP is a significantly (p-value < 0.001) more common presentation in women with GBV.
It may also imply that for women who cannot otherwise express their psychological trauma, pain abdomen is the effect of somatization.
The incidence of vaginitis in this study was 27.90% among GBV sufferers and 33.74% among nonsufferers. Though the prevalence is more in GBV sufferers, prevalence is still lower than the 40% in pregnant women as reported by Lamichhane.20
Though the prevalence of all studied clinical conditions was higher in women facing abuse, CPP was significantly higher in these women.
Role of Health Workers
Gender-based violence is a barrier in attaining high levels of reproductive health, and health care providers are in a unique position to offer care, support, and counseling that could be of help to the survivor.21
Despite high prevalence of emotional, physical, and sexual abuse in patients visiting gynecology clinics, most victims of abuse are not identified by their gynecologists, which might increase the risk of abused patients not being treated according to their needs. Studies show that most women (92–98%) had not talked to their gynecologist about their experiences of abuse at their latest clinic visit.6,22 So in order not to miss these women, health personnel should always consider asking patients about abuse.
According to the international human rights law, all countries have to commit to prevent, prosecute, and punish violence against women.5 Women do not seek help for GBV as it is considered a family business, so intervention is not easy. A hospital being a place where women present with their problems, this should be considered as a primary site for detection and prevention. Screening in the OPD, especially in gynecology, will be of benefit in restoring the health of these women and will also decrease the burden to health institutions. It is a challenge to medical professionals to see beyond symptoms and work toward complete care for women. If this can be done, slowly women will start confiding in health professionals and the detection rate will increase.
There are certain societies where domestic violence is reported to be virtually absent, so can it be in Nepal if medical professionals work toward attaining complete health care for women.23,24
LIMITATIONS
The study population was limited to the women attending gynecology OPD only; therefore, the study findings cannot be generalized to all patients. Gender-based violence in pregnancy and pregnancy-related problems is a widespread entity which has not been addressed by this study. Also, the diagnosis of various gynecological problems was only clinical. The laboratory findings might change the diagnosis and prevalence of the various reproductive health conditions among women facing abuse.
CONCLUSION
Gender-based violence is prevalent in women attending gynecology OPD. Emotional abuse is the commonest type of abuse, but severe abuse is faced by women suffering sexual abuse. These women present with pain abdomen and CPP, so it is of importance for health professionals to screen all patients presenting with gynecological problems to identify victims of GBV. Gynecology OPD of a tertiary hospital could be used as a screening setting which can assist in early detection and prevention of GBV in Nepal.