Gender-based violence and the threat to women’s mental health

Recent research has shown a striking association between gender-based violence (GBV) and lifetime mental disorders among Australian women.1 Data from the 2007 National Survey of Mental Health and Wellbeing2 offer important lessons for advancing policy and practice in this key area of human rights and public health. More than a quarter of the 4451 women surveyed had experienced one of the common forms of gender-based violence (GBV): rape (8.1%), other forms of sexual assault (14.7%), physical intimate partner violence (7.8%) and stalking (10.0%). Sexual assault and rape often occurred for the first time at an early age (median 12 and 13 years, respectively). GBV was strongly associated with a wide range of mental disorders including mood, anxiety and substance-use disorders; women exposed to one form of GBV had double the rate of any lifetime mental disorder (58%) of unexposed women (27%). GBV was also strongly associated with severity and comorbidity of mental disorder, suicide attempts, disability, poor quality of life, unemployment and overall socioeconomic disadvantage.

Although major advances have been made in developing practice guidelines and policy to prevent and respond to GBV in Australia, there has been little focus on the mental health component. This oversight continues to be evident in the Australian Government’s 12-year action plan,3 which otherwise offers a comprehensive approach to the problem.

The prevalence and consequences of GBV mean that it needs to be regarded as a mainstream problem for all health care providers. The primary care level is of pivotal importance. General practitioners need to be aware of the likelihood that undisclosed GBV may underlie unexplained physical injuries and mental health symptoms, particularly among repeat attenders. There is a risk that the culture of silence on this issue will hinder detection of the problem.4 Women justifiably fear that they will not be believed or that their disclosures will put them at risk of further abuse, and clinicians may be hesitant to raise this sensitive topic. The presence of partners at consultations can further inhibit disclosure. GPs may benefit from additional training in gender-sensitive interviewing techniques, to ensure accurate detection of GBV in a manner that builds trust.5 National protocols need to be implemented for referral and coordination among agencies so that women have access to protection (shelters and/or the removal of perpetrators from the household), legal advice, support for at-risk children, and financial assistance. Access to quality mental health services should be a priority, given that the disorders identified by the national study were complex in nature, disabling and associated with suicide risk.

Specialised agencies, including mental health, rape crisis and domestic violence services, need to recognise more fully the close interaction between GBV and mental disorder. Mental health professionals should maintain a high level of suspicion that GBV may underlie common mental disorders. Sensitive inquiry into a history of abuse is an integral part of assessment. Abused women should be protected from situations that increase feelings of insecurity; for example, mixed-gender facilities or settings where male partners can gain ready access. Services for sexual assault and domestic violence require better resourcing to ensure seamless referral to mental health professionals with the necessary skills to address the psychological consequences of gender-related abuse. The process of referral needs to allay the woman’s fear of being labelled in a context where perpetrators commonly try to discredit reports of abuse by claiming the survivor is mentally disturbed.

The study findings1 point to the importance of childhood, adolescence and early adulthood as targets for interventions. It is during these early developmental phases that women commonly are first exposed to sexual abuse, which is the harbinger of further violations as well as of a lifetime of mental disorder and disability. A greater focus on school-level and family interventions may prove valuable. The family is the setting of highest risk, but it is also the unit with the greatest potential to provide protection. At a wider level, public health campaigns are needed to change attitudes and mores that sanction the culture of patriarchy and silence surrounding GBV in our society.6,7

The strength of the nationwide epidemiological study1 is that it offers a lifespan perspective on the recursive problem of GBV, in which women are at risk of repeated exposure to abuse of various forms, and of developing a range of comorbid mental disorders and associated disabilities. Socioeconomic disadvantage and marginalisation compound the problem. Women with limited resources and alternatives are less able to leave a violent relationship. Indigenous women and women from refugee backgrounds may be confronted with additional problems related to discrimination and isolation.8-10

A sustained and coordinated multisectoral approach, in which mental health has an integral role, is vital to bringing about fundamental change to the life-course trajectory of adversity associated with GBV. The overarching aim should be to provide a comprehensive approach to intervention that empowers women to make the changes required to promote recovery and resilience.