Students at Columbia University carry mattresses on the Carry That Weight National Day of Action to show their support for survivors of sexual assault. Credit: Warren Heller

By Lyndal Rowlands
UNITED NATIONS, Nov 25 2014 (IPS)

“A recurring nightmare for me is I’m trying to tell someone something and they are not listening. I’m yelling at the top of my lungs and it feels like there is a glass wall between us.”

Jasmin Enriquez is a two-time survivor of rape. Like two-thirds of rape survivors, Enriquez knew her rapists. The first was her boyfriend when she was a high school senior, the second a fellow student she had been seeing at college."What I hear from women is that they are told to shut up: they are told to shut up during it, they are told to shut up after it, and they are told by some institutions to continue keeping their mouths shut." -- Dr. Dana Sinopoli

“[The nightmare] shows how I’ve always felt that even as someone coming forward as a survivor, as soon as I start giving details to some people, they instantly start to shut it down. As in, you’re being crazy or hyperemotional, instead of taking it as one whole piece and looking at it holistically,” Enriquez told IPS.

Women who have experienced gender-based violence are at a significantly increased risk of developing a mental disorder, such as post-traumatic stress disorder, anxiety or depression, within one to three years after the assault.

Enriquez explains, “People don’t seem to understand that after being sexually assaulted, it’s something that you have to live with the rest of your life.

“Most of the time there is an incredible amount of anxiety or depression or other mental health issues that people just don’t understand,” she says. “It’s been five years since I was sexually assaulted and I still live through the trauma.”

A special Lancet series published Friday says that one in three women have experienced physical or sexual violence from their partner.

Researcher Dr. Susan Rees from the University of New South Wales told IPS that there is strong evidence that if you are exposed to gender-based violence, you are at a much higher risk for the onset of post-traumatic stress disorder (PTSD), anxiety and depression as well as attempted suicide.

Rees’ research into the connection between gender-based violence and mental disorders has shown that women who have been assaulted are significantly more likely to experience a mental disorder in their lifetime.

Women who have experienced one form of gender-based violence have a 57 percent chance of developing a mental disorder compared with only 28 percent of women who have not experienced gender-based violence. Significantly, 89 percent of women who have experienced gender-based violence three to four times will develop a mental disorder.

It is important for survivors of assault to get early support to help prevent the onset of an associated mental disorder, Rees said.

However, experiencing sexual assault can be confusing, especially for young women and girls, and this may prevent them from getting early intervention.

Enriquez explains that she didn’t initially realise the connection between her response to the trauma of sexual violence and the symptoms she was experiencing.

“I’ve recently been very jumpy, kind of always tense and I get startled easy, I didn’t understand why that was happening and it was very frustrating.”

Enriquez’ fiancé, who is not the person who assaulted her, used to jump out at her or play games to surprise her, and she found this really upsetting,

“I didn’t understand that it was related to me being sexually assaulted until probably my senior year of college. I feel like if I had been educated about what normal symptoms are of PTSD, I would have known that there was more to it and that it was a normal piece of it.”

Community attitudes affect prevalence

Community attitudes towards women, including strong patriarchal attitudes, power imbalance and gender inequality contribute to the prevalence of violence against women, said Rees.

“It makes sense that if you change attitudes then you can change prevalence, you can reduce the risk for women,” she said.

This is what Enriquez aims to do with her organisation Only With Consent. Together with her fiancé, Enriquez speaks with students to raise awareness and change young people’s attitudes towards sexual assault.

“I definitely think that there’s a gender piece that goes with both the mental health and the sexual assault and that it ties back to any time a woman expresses an emotion of being angry or upset we immediately call her out for being irrational or emotional.” Enriquez told IPS.

“If the majority of survivors who are speaking out are women, and they are expressing these feelings of being upset or being angry, or being really hurt, or any of those feelings, we discredit what they are saying, because we see them as irrational creatures,” Enriquez said.

Psychologist Dr. Dana Sinopoli told IPS that it is also important to consider how gender-based violence affects men, especially men who experience childhood sexual assault. She said that this should involve addressing gender stereotypes such as that men are aggressive or impulsive.

As Carry That Weight explains on its website:

“People of all gender identities can experience and be affected by sexual and domestic violence—women are not the only survivors just as men are not the only perpetrators. We strive to challenge narrow and inaccurate representations of what assault looks like and also acknowledge that these forms of violence disproportionately affect women, transgender, gender nonconforming, and disabled people.”

Sinopoli added however that changing community attitudes towards women was an important part of addressing gender-based violence.

“Consistently what I hear from women is that they are told to shut up, they are told to shut up during it, they are told to shut up after it, and they are told by some institutions to continue keeping their mouths shut.

“That is what we can link to the depression and the anxiety and a lot of the re-experiencing and retriggering that is so central to PTSD,” Sinopoli said.

Sinopoli added that “the way that society reacts, to someone who discloses or is struggling, is so important.

“The more that people speak up the more that we will actually see a decline in such significant psychological symptoms.”

Early intervention can help

When helping someone who has experienced violence, Rees said that it is important that friends and family reassure the victim that it “it is never acceptable to be hit, or to be treated violently or to be raped.”

Unfortunately, population studies show that women who have experienced gender-based violence are also at increased risk of experiencing it again in their lifetime.

“This might be the case because often men target women who are vulnerable, so if she has a mental disorder or trauma as a result of an early childhood adversity, she may be more likely to be targeted by men who in a sense benefit from powerlessness, inequality and fear.”

She said that warning bells that a relationship is unhealthy include controlling, jealous behaviour such as telling you who you should socialise with, or getting jealous because you are doing better than he is at university.

“Often women think that’s because he cares about me, he’s worried about me and that why he wants to know where I am all the time,”

But this type of behaviour should actually be seen as a warning of future emotional and perhaps physical abuse, Rees said.

Rees said that the reasons women don’t leave violent relationships are complex,

“She may be suffering depression. She may not have the economic resources to leave. She may worry about the children, and rightly so, because often people end up homeless, and she also may know that she’s at high risk of retaliation from the perpetrator if she leaves.”

Rees also explained that it is important for health practitioners to receive training so they can be confident to ask about domestic violence and respond appropriately.

She added that primary health care responses need to be integrated with community-based services to ensure that survivors have access to help that is sensitive to the complex impact of sexual violence.

Edited by Kitty Stapp

Of the 100 patients seen at Kashmir’s psychiatric facilities each day, roughly 75 are women. Credit: Shazia Yousuf/IPS

By Shazia Yousuf
SRINAGAR, India, Nov 19 2014 (IPS)

It was almost midnight when Mushtaq Margoob woke up to the incessant ringing of his phone. It was his patient, a young woman whom Margoob, a renowned Kashmiri psychiatrist and head of the department of psychiatry at the only psychiatric hospital in Kashmir, had been treating for depression for many years.

“See me now. I don’t have time till tomorrow,” the patient screamed down the phone. “I might have killed myself by then.”

The woman was educated, had a PhD in Bioscience and came from a rich family. After her marriage last year, the symptoms of her depression had begun to fade away, and she had started crawling back to a normal life.

“I have gifted lifelong sadness to my daughter.” -- Shahzada Akhtar, a Kashmiri woman living with PTSD
But the day she made the hasty phone call to the doctor, she had learned something that shattered her life into fragments all over again.

“I have been diagnosed with Premature Ovarian Failure [POF],” she said to Margoob at his home. “If I cannot have any children, what should I live my life for?”

Although Margoob was able to pacify her with timely counseling and medication, the diagnosis and the constant reminder of being infertile have taken his patient back into deep depression.

“The mental stress due to ongoing conflict has taken a toll on the physical health of young women, especially their maternal health,” explains Margoob.

Downward spiral of mental and maternal health

The conflict here, which dates back to the 1947 partition of India and Pakistan, has claimed some 60,000 lives as Indian armed forces, Pakistani troops and ordinary Kashmir citizens struggle to assert control over the bitterly contested region.

The “pro-freedom” uprising of 1989, launched by Kashmiris who resented the presence of Indian and Pakistani troops, morphed into a long-standing resistance movement that has left deep scars on Kashmiri society.

As a result, the area known as the Kashmir Valley, tucked in between towering mountain ranges in the northern Indian state of Jammu and Kashmir, is witnessing an alarming increase in childlessness and infertility among local women.

Infertility is becoming increasingly common among young Kashmiri women, who are suffering from stress and trauma due to the long-standing conflict in the region. Credit: Shazia Yousuf/IPS

Physical and mental health experts cite conflict-related stress as the main cause of the health crisis among women, which has robbed thousands of their fertility.

The most recent Indian National Family Health Survey (NFHS) indicates that 61 percent of currently married Kashmiri women report one or more reproductive health problems.

This is significantly higher in comparison to the national average of 39 percent. The percentage of POF among infertile women below 40 years of age is also abnormally high – 20 to 50 percent – when compared to the nationwide rate of one to five percent.

“Stress causes structural changes in the brain and disturbs the secretion of various neurotransmitters. These changes lead to various physical ailments including thyroid malfunction, which in turn can cause infertility among women of childbearing age,” Margoob explains to IPS.

According to statistics available with the Government Psychiatric Diseases Hospital, 800,000 Kashmiris are suffering from Post Traumatic Stress Disorder (PTSD) and most of them are women. PTSD, like many other mental health disorders, directly affects women’s childbearing capacity.

Stress and stigma

In Kashmir, psychiatry OPDs are run at two hospitals – the Shri Maharaja Hari Singh (S.M.H.S) facility in Srinagar, and the Government Psychiatric Diseases hospital – six days a week. Of almost 100 patients seen at each OPD every day, 75 are females.

One of the many women who frequents these facilities is 20-year-old Mir Afreen, who grew up watching her mother battling mental illness. In 1996, when Afreen was only two, her mother, Shahzada Akhtar, received a message about the death of her cousin brother in cross-fire.

“I had met him only a day before. I couldn’t believe he had died. I tried to cry out his name but had lost my voice,” recalls Akhtar.

Akhtar never recovered from the sudden, devastating news, and soon developed PTSD.

In consequence, her daughter’s childhood quickly slipped into darkness. Afreen often saw her mother sedated, sleeping for days at a time, going without food, and crying for no apparent reason.

She was always taken along to psychiatric clinics, hospitals and faith healers where her mother searched for a cure for her condition. Happiness was far, far away from their home.

“I have gifted lifelong sadness to my daughter,” Akhtar tells IPS tearfully.

Her statement is not too far from the truth. For the last several years, Afreen has been complaining about chest pains and breathlessness. Akhtar first thought it was due to stress, or her daughter’s recent obesity.

But when Afreen developed facial hair and her monthly cycles became irregular, Akhtar took her to a gynecologist.

“The doctor uttered a long name which I couldn’t understand, so I asked her to explain the [condition] to me,” Akhtar says. “She told me if this is not treated, Afreen will never have children.”

Afreen was diagnosed with Polycystic Ovarian Syndrome (PCOS). Unknown and almost non-existent before the conflict, the syndrome now affects 10 percent of Kashmiri females including teenagers.

A major endocrine disorder in women of reproductive age and one of the leading causes of infertility across the world, PCOS has emerged as another major cause of infertility among Kashmiri women in recent years.

Medical experts have identified stress as one of the main reasons for the emergence of PCOS in Kashmir. A study conducted by Sher-i-Kashmir Institute of Medical Sciences (SKIMS), the major tertiary healthcare facility in Kashmir, on 112 women with PCOS, found that 65 to 70 percent of them had psychiatric illnesses including PTSD, depression and Obsessive Compulsive Disorder (OCD).

Akhtar feels helpless. Unlike other ailments, Afreen’s particular health issue is not up for discussion, not even with her own siblings. If the word spreads, she thinks, it will ruin her daughter’s marriage prospects and thus destroy her life.

“Even when I take her to the doctor, I make sure that no one sees us,” reveals Akhtar. “I first check the place and then let my daughter in.”

Afreen does the same. She has not revealed anything about her condition to her friends. When the girls talk about their grooms and life after marriage, she keeps mum. When it is the time for her medication, she secretly swallows the pills without water.

Current trends predict a bleak future

Nazir Ahmad Pala, an endocrinologist at SKIMS, says that more and more young females visit the endocrinology department for various disorders. A good number of disorders, he says, are born from depression.

Anxiety over the possibly loss of male breadwinners is prompting many women to choose education and employment over marriage. Credit: Shazia Yousuf/IPS

“In the past, the department received mostly older patients but now around 20 percent of our patients are school and college going girls with endocrine abnormalities. This trend is disturbing,” Pala tells IPS.

The young girls mostly complain of obesity and ovulatory disturbances that bring a temporary halt in their menstrual cycles.

The condition is called Central Hypogonadism and is common in depressed women, explains the doctor. Another equally frequent ailment is galactorrhea, a spontaneous secretion of milk from the mammary glands due to an abnormal increase of prolactin levels in the body caused by antidepressant intake.

“Unfortunately most of the [conditions], in one way or the other, lead to infertility. And the root cause of all these [conditions] is the stressful life that women have been living in the post-conflict era,” Pala asserts.

Experts here are sounding warnings about the catastrophic shape that women’s health in the Valley is taking. A study conducted at SKIMS on maternal health indicates that 15.7 percent of Kashmiri women of childbearing age will never have an offspring without clinical intervention.

Another conflict-related cause of infertility among Kashmiri women is late marriages. Over the war years, the marital age has risen from an average of 18-21 to 27-35 years. Because of economic insecurity and anxiety over the prospect of losing male breadwinners, women are choosing education and employment over marriage.

“Economic instability and insecurity is eating our society like termites,” says Margoob.

The doctor reveals that cut-throat competition in schools and colleges to earn a secure future has hugely disturbed the mental health of young girls as well.

Dissociative Disorders (DD), marked by disruptions or breakdowns in identity, memory or perception, are rapidly increasing in young school- and college-going girls, along with conditions like Panic Disorder, all of which interrupt the “smooth journey to motherhood”, Margoob says.

*Patients’ names have been changed on request.

Edited by Kanya D’Almeida