he 16 days of activism campaign of the United Nations against gender based violence begins on November 25 – the International Day for the Elimination of Violence Against Women. This year’s theme is “UniTE! Invest to prevent violence against women and girls.” It is focused on a global call to civil society, organisational systems and governments to fund and support prevention strategies to proactively stop gender-based violence.

Violence against women and girls remains the most pervasive human rights violation around the world. UN Women has found that more than five women or girls are killed every hour by someone in their own family; almost one in three women have been subjected to physical and/ or sexual violence at least once in their life; and 86 percent of women and girls live in countries without legal protections against gender-based violence. Pandemics, climate change and conflicts have exacerbated the problem and the statistics are worse in workplace and online settings.

As we chew on these dismal statistics, it is important to understand that the experience of violence breaches basic human right to liberty and security of the person and freedom from fear. The presence of violence is incompatible with the highest attainable standard of physical and mental health. The WHO defines mental health as “the state of well being in which the individual realises her or his own abilities; can cope with the normal stresses of life; can work productively and fruitfully; and is able to make a contribution to community.” It is also critical to appreciate the intersectionality of violence, mental health and gender, where women and girls are more vulnerable to effects of mental health determinants like poverty, biological risks, oppression, social exclusion, patriarchal structures, income disparities, unremitting responsibility of care for others, access to diagnosis and treatment. There is burgeoning data that globally women are disproportionately affected by gender based violence. Culture-specific abuse starts at conception with sex-specific abortions. It continues through life in the form of domestic violence, rape, sexual harassment, incest, workplace abuse, ‘honour’ violence, trafficking, stove burnings and elder abuse. Often violence is embedded in many societal structures and institutions and therefore, endemic in many aspects of women’s lives.

There is clear evidence to show that experiencing violence, either pervasive or as a severe one time occurrence, puts the victim at risk for mental health disorders. Victims of violence are three to five times more susceptible to anxiety and depressive disorders, substance abuse, post-traumatic stress disorders and suicidal ideation. Female victims of gender based violence are at higher risk of developing mental health related symptoms; the prevalence of depressive disorders in women living in shelter home is about 50 percent; over 30 percent have reported symptoms of PTSD.

There are important layers to be considered here; minimising the connection between violence and mental health may lead to misdiagnosis, inability to access help or dismissal of symptoms requiring specialised healthcare. The presence of substance abuse by victims as a coping mechanism may make the process of diagnosis murkier, elicit counter transference by practitioner and make treatment options challenging. Benzodiazepines are widely prescribed in Pakistan by general physicians and psychiatrists as a blanket band aid for all kinds of distress related symptoms; these often lead to addiction, labelling and unclarity of diagnosis and management options.

Frequently, stigma associated both gender-based violence and mental health concerns can prevent survivors from sharing their experiences, reporting incidents and accessing support. Other contextual concerns like threat of divorce, being ‘kicked out’ of the married house, losing access and custody of children due to being labelled as having a mental health disorder, as well as minimal to no health and social support systems, all may keep survivors from disclosing their experiences. Often a diagnosis of mental health disorder may be used as a justification for the abuse and the experience of violence discredited for these victims.

The aftermath for adolescent girls and female children experiencing violence may be exceptionally detrimental. Traumatic events have different effects during the teenage years, when the brain is still developing. Adolescents are at higher risk of sexual assault than any other age group. This is also the time when mental health problems often start. Most teenagers who reported sexual assault or other forms of physical violence exhibit symptoms of post-traumatic stress disorder, anxiety or depression and social exclusion within six weeks of the assault. Abuse also leads to disturbed sleep, anxiety, brain fogginess, cognitive disturbance, self-harm behaviours, often leading to poor school attendance and worsening academic performance for those attending school. Victims of sexual abuse are more likely to have early or multiple sexual partners, and to have relationship problems with friends, families or partners.

It is quite clear that navigation of this societal affliction requires multiple considerations, including discerning policies and practices that keep the victim at the centre. While there is clear evidence that experience of violence puts victims at risk for mental health disorders, immediate distress or grief reactions to abuse are often normal responses to an adverse event and must not be pathologised. Principles of care must include a victim-centred approach that promotes safety, confidentiality, non discrimination and agency of the survivor. In a cultural and contextual backdrop, where women are mostly silent and have men speak for them, this may often be a challenging task; therefore, more care and respectful creativity is required to cater to agency and engage these women and girls as active partners in their care. Emotional and mental health effects must be differentiated from mental health disorders and good quality psychosocial support must focus on empowerment and recovery, while assessing pragmatic risk mitigation. None of this is possible if policy and systems do not stand accountable to civil society and address harmful social norms, stigma, health and gender inequities.

The writer is a consultant adult, child and adolescent psychiatrist. She is the founder and CEO of Synapse, Pakistan Neuroscience Institute