- (2013) Volume 10, Issue 2
Mary Dawood RN BSc (Hons) MSc
Nurse Consultant, Imperial College NHS Trust, London, UK.
International Women’s Day 2013 had as its theme ‘The Gender Agenda.’ The focus of the day was on ending violence against women and girls. According to UN figures, up to 7 in 10 women globally will be beaten, raped, abused or mutilated during their lifetime, and although around 125 countries have laws that penalise domestic violence, there are still around 603 million women who live in countries where such behaviour is not a crime.
These figures highlight just how vulnerable women are all over the world, and this fact was brought closer to home recently when a young woman of Chinese origin attended the Emergency Department with a significant injury to her hand. She was assessed and treated by the nurse practitioner and given a follow-up appointment for the following week at a specialist Hand Clinic at another hospital nearby. The woman spoke reasonable English and had given a plausible history of having injured her hand herself. The following week she re-attended the Emergency Department, complaining of ongoing problems with her hand. It was clear that she had not kept the appointment at the Hand Clinic that had been arranged for her. The nurse assessing her asked the woman why she had not kept her appointment, but she was vague in her response and requested to see the nurse practitioner or a doctor again as she now also had earache. The nurse initially felt mildly exasperated with the woman, as she was not forthcoming, but nonetheless referred her to the nurse practitioner.
After a lengthy and tearful consultation with the nurse practitioner it emerged that the woman was a victim of domestic violence. Her partner had deliberately injured her hand and had subsequently hit the side of her head with considerable force, causing a ruptured eardrum. She told the nurse that prior to migrating to theUKshe had lived with her partner and his family in China, where he had occasionally been violent towards her. This behaviour had not been frowned upon by his family, and she felt that the only way to change his behaviour would be to move away from his family, and he had agreed to migrate with her to the UK. Sadly, but not surprisingly, his behaviour continued when they were living in the UK. Therefore, in addition to living in fear of his temper, she had to contend with the feelings of alienation and isolation that are so often the plight of the immigrant. She had no friends or family in the UK, and no idea where she could turn for help. She was fearful of her partner’s response if he discovered her ‘betrayal’ of him to the authorities, and had certainly not considered informing the police, as she had no understanding of the system and the fact that the police would be willing to help her.
The nurse practitioner felt very concerned for the woman, and encouraged her to report the assault to the police.However, as is so often the case with victims of domestic violence, even those native to the UK, she was most reluctant to do this. The nurse put her in touch with social services and gave her the addresses of local women’s aid organisations, explaining their role and hoping that she would have the courage to approach them for help. This was a very sad encounter, and unfortunately not an unusual one, as violence against women is becoming increasingly common. It is not just a local problem, but a global phenomenon and a serious health and social problem worldwide (United Nations Statistics Division, 2011). There is ample evidence which consistently demonstrates that women and girls worldwide are subjected to various forms of violence by family members, neighbours, and men in positions of authority, such as the military and the police (Crawley and Lester, 2004; Garcia-Moreno et al, 2006). The reported rates for women experiencing physical violence at least once in their lifetime vary depending on where in the world they live, but can be as high as 70% (United Nations Statistics Division, 2011).
Domestic violence, which is sometimes referred to as intimate partner violence (IPV), is no discriminator of race, colour, creed or indeed social class. Most but not all of the victims are women and girls, and both of these groups are still more at risk of violent crime in their homes than anywhere else. Although there has been considerable research into the nature and causes of domestic violence, the focus of research has been of a general nature, and there is still a paucity of research into the unique and specific experiences of immigrant and refugee women and the impact of migration, both forced and voluntary, on their domestic relationships.
Qualitative research in this area is fraught with difficulty, not least in defining and agreeing what is domestic violence. The subject is at best unpalatable, and so remains cloaked in deception. In many cultures the subject is taboo and therefore is not discussed, and victims are often stigmatised and blamed as having invited such violence by their behaviour. Because of this, victims are often too frightened and ashamed to talk about their experiences, particularly if they are still dependent on their abuser, and they are usually reluctant to report abuse even when pressed to do so. As a result, violence against women is almost universally under-reported (Watts and Zimmerman, 2002). Although domestic violence is deplored and considered unacceptable in most western nations, and perpetrators can be charged, this is not the case in many other countries. The plight of immigrant women who are victims of domestic violence is compounded by their status as immigrants, with perhaps limited language skills and little knowledge of their rights or the refuge that may be available to them. They may also fear being excluded from their community, which may be the only source of stability and the only link to their previous life and country of origin.
Healthcare workers need to be mindful of these facts, and also to remember that attitudes to domestic violence vary between cultures, and such behaviour may not be frowned upon but rather may even be deemed acceptable in more patriarchal societies where there may be no laws in place to protect women from intimate partner violence. The self-esteem of some victims is so low that they believe their abuser to be justified in their behaviour, which perpetuates and exacerbates the violence.
In addition to these cultural issues, the evidence suggests that the often chaotic process of migration, particularly forced migration, and the difficulties associated with living in exile and readjustment render women more vulnerable to IPV (Guruge et al, 2010). In the early days of arrival in a new country, the social and economic barriers to integration and acceptance by the host community, coupled with unemployment, poor living conditions or having to undertake unsuitable jobs, can all add to stress, mitigating against harmony in the home environment (Guruge et al, 2010). An imbalance in the gender dynamic, where the woman has a better job than the man, or even the woman merely having a job outside the home, can be a source of anger and humiliation for the man who has traditionally seen himself as the provider and head of the family.
Violence against women, and particularly domestic violence, leaves indelible marks which can be the cause of long-term physical and psychological ill health (Briere and Jordan, 2004), and this constitutes a major public health problem. Given that approximately 50% of all immigrants are women and they are the main carers of children, there is a requirement for greater awareness among healthcare professionals about the need to be vigilant and to maintain a high index of suspicion when caring for this vulnerable group. As healthcare professionals we have a responsibility to actively endorse the aspirations of ‘The Gender Agenda’ to work towards ending violence against women and girls. We should consider the words of the Secretary- General of the United Nations in his message to mark International Women’s Day 2013:
Look around at the women you are with. Think of those you cherish in your families and your communities, and understand that there is a statistical likelihood that many of them have suffered violence in their lifetime.
(Ban Ki-moon, 8 March 2013)
