The “shadow pandemic” of domestic violenceBMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n2166 (Published 14 September 2021) Cite this as: BMJ 2021;374:n2166
Nila, 30,* cradled her baby in one arm as her other hand was badly sprained. During India’s first covid-19 lockdown she was confined to her New Delhi flat with her abusive husband. Things came to a head in January when he beat her so badly that she could barely use her hand.
“I also have severe abdominal pain and vaginal discharge. I am very anxious too,” she said in February 2021. She didn’t have a job or an income, so she sold trinkets on the roadside by day. At night, she came home to physical, sexual, and verbal abuse.
Nila is one of millions of women in India whose situation worsened during the lockdowns. Since the pandemic began, reports of domestic violence have soared, prompting the United Nations to call for urgent action against what it calls “the shadow pandemic.”1
Before the pandemic, gender based violence was already the leading cause of ill health, disability, and death for one in three women globally—around 736 million in 2018.2 Nearly 35% of women in South Asia, the Middle East, and Africa, and 20-30% in the Americas and Europe faced violence by an intimate partner.34 One in three women reported domestic violence during or soon after pregnancy in India, Pakistan, Kenya, and Malawi.5 By June 2021, five months into the pandemic, reports of domestic violence to India’s National Commission for Women had reached a 20 year high.6
“The problem is universal,” says Avni Amin, technical officer with the Department of Sexual and Reproductive Health and Research at the World Health Organization. “Domestic violence survivors report problems in two categories: mental health, and sexual and reproductive health.”
“There is always a long queue of women outside the local government hospital complaining of the same issue: vaginal discharge,” said Renu,* a 26 year old woman from New Delhi. Renu reported that many of her neighbours had experienced gender based violence.
Both Renu and Nila have had abnormal vaginal discharge, a condition that affects nearly a quarter of women in South Asia.7 Discharge is a common symptom among those who face intimate partner violence, says Ankita Abhay, medical activity manager at Umeed Ki Kiran (UKK), a New Delhi based clinic run by Médecins sans Frontières for people who have encountered gender based violence. “Sometimes it is a symptom of sexually transmitted infections (STIs), which they may have acquired from their partners,” she says.
Renu said her condition had led to excessive itching and odour. It could also lead to skin abrasions, boils, and even bleeding. Both she and Nila weren’t aware that abnormal vaginal discharge is a symptom of some STIs, until they were asked to get a test. Both said they tested negative for STIs but the problem persisted.
Abhay says that if abnormal vaginal discharge isn’t related to STIs, then it’s often linked with mental stress and trauma. A 2005 study published in the International Journal of Epidemiology of 2494 women from Goa noted that those who experienced verbal abuse, sexual violence, and concerns regarding their partner’s extramarital relationships were more likely to present with abnormal vaginal discharge.7 Studies in other parts of South Asia and Africa have shown similar results.8
“Doctors may not always find a physiological cause for some complaints that women present with,” says Amin, “but they miss out on violence as a cause, because they don’t ask about it.”
Abnormal discharge is often caused by reproductive tract infections (RTIs). However, in Bangladesh and India only 30% and 60%, respectively, of women reporting vaginal discharge receive a confirmed diagnosis of an RTI.9 This has led to inappropriate treatment. Apart from the economic cost, some women are stigmatised by receiving the diagnosis of an RTI or STI.9 Studies note strong links between abnormal vaginal discharge, depression, and other mental disorders among women.10
“If you’re living in an abusive relationship, then stress and anxiety are a constant companion so you will have a range of non-specific complaints,” Amin said. In addition to problems with sexual, reproductive, and mental health, people experiencing domestic violence may also report irritable bowel syndrome, psychosomatic symptoms, high levels of anxiety, and headaches.
At the UKK clinic, psychological counselling is now part of the treatment plan for abnormal vaginal discharge.
“The physical implications of violence are usually obvious so people only look at that,” says Kiran Bhatia, a gender specialist and former regional adviser for the UN Population Fund, “but often the trauma and the psychological implications have ripple effects on mental health and wellbeing of survivors.”
Women in South Asia who are living with domestic abuse are three times more likely to experience gynaecological pain, tenderness, bleeding, abrasions, wounds, and genital itching, or anal pain and bleeding, than the general population.1112
According to a review of 4818 research articles published in BMC Pregnancy and Childbirth13 maternity care in low and middle income countries lacks screening, referral, and management interventions for women who experience postpartum domestic violence, resulting in high morbidities. Women often report the immediate results of domestic violence such as injuries, STIs, hepatitis B, tetanus, and unwanted pregnancies, but little consideration is given to the longlasting medical consequences such as pregnancy complications, unsafe abortions, infertility, and chronic pain, says Meggy Verputten, a specialist in gender based violence at Médecins Sans Frontières.
Women experiencing intimate partner violence are 1.5 times more likely to acquire HIV infections, and to contract syphilis, gonorrhoea, and chlamydia.14 They are twice as likely to have abortions, and 16% more likely to have babies of low birth weight. They also have reduced access to medical care and antenatal or family planning services.
During the pandemic, the local government hospital in New Delhi has admitted only patients with covid-19. Outpatient clinics for obstetrics and gynaecology have opened for only two hours a day, resulting in long queues and doctors only attending emergency cases.
Nila told The BMJ she could not seek first aid at the government hospital after her husband beat her in January because he wouldn’t allow it. Such instances are not uncommon.
“Such violence is linked to power within the domestic situation and the relationship between survivor and perpetrator. Women may have limited access to medical care, for example, contraception, due to restrictions imposed by their partner, husband, or even mother in law,” Verputten said.
Grassroots organisations are now paying more attention to domestic violence. Sangath, a Goa based non-profit group and the Mumbai-based Centre for Enquiry into Health and Allied Themes are working with patients and local government to ensure provision of healthcare to those experiencing abuse.
Clinics like the UKK in New Delhi, meanwhile, are providing holistic healthcare to people experiencing gender based violence. UKK has separate rooms for triage, counselling, consultation, and examination where only patients and healthcare providers are admitted, to ensure privacy and confidentiality.
Abhay says patients are often highly anxious or not well enough to be examined, and are advised to see a counsellor first. “We decide our consultation based on the triage and what the patient wants. We have protocols for different age groups,” she said. Patients can be referred to other health centres, or offered consultations with social workers and medico-legal professionals.
Amin welcomes the active role that healthcare workers are taking. “Violence takes away a woman’s power,” says Amin, “As a healthcare provider, your role is to give that power and autonomy back to the patient.”
*Names changed to protect the privacy of the patients.
Commissioned, not externally peer reviewed.
Competing interests: I have read and understood the BMJ policy on declaration of interests and declare the following interests: I was a Médecins Sans Frontières Media Fellow in 2020.