ender based violence is a severe societal and public health problem, making it one of the foremost global health challenges of our times. It can lead to a variety of health issues, including physical and psychological damage; adverse effects on the sexual and reproductive health of women and adolescents; disability; and death. The United Nations defines GBV as any act of violence against a person based on their gender that results in or is likely to result in physical, sexual or psychological harm or suffering. Although it can occur on any gender, GBV is by far more common in women and adolescents. As a societal problem, it is a human rights violation, a form of discrimination, and is often a symptom of historic and current inequalities of power that exist between men and women. It is relatively more prevalent in cultures with traditional make, hierarchical and patriarchal structures.

GBV is a pervasive issue; almost one in three women (35 percent) across the world have experienced some form of violence at least once in their lifetime. According to a WHO report, the consequence of GBV include unwanted pregnancies, induced abortions, gynaecological problems, sexually transmitted infections, psychological trauma and death.

Gender-based violence takes many forms. It can manifest as physical, sexual, emotional, psychological and economic abuse; harmful practices such as forced and child marriage; ‘honour’ killing; female genital mutilation; murder; sex trafficking; threats of such acts; and coercion or arbitrary deprivation of liberty.

The mental health link

GBV and mental health are distinct yet intertwined in their causal relationship. Mental health has clearly emerged as one of the most urgent global crises of our times. Post Covid-19, the world has seen a 25 percent increase in the prevalence of mental health disorders, especially among women and the youth. The pandemic was also responsible for a sharp increase in GBV.

Mental health is a state of emotional, psychological and social well-being. Mental distress, on the other hand, is defined as a state of emotional suffering characterised by the undifferentiated combinations of symptoms of depression and/ or anxiety (eg, restlessness; feeling tense) that may have an impact on the social functioning and day-to-day living condition of individuals.

Studies from around the world have shown that survivors of GBV are at a higher risk of developing depression, anxiety, post traumatic stress disorder and peri- and post-natal mental health disorders. They may also often resort to substance abuse to cope with the effects of violence. Suicide risk is also considerably higher in GBV victims. Other effects on mental health include, trouble sleeping, neuropsychological deficits, headaches and fibromyalgia.

While there is clear evidence that GBV is more prevalent in the Global South, with the highest figures, according to the WHO, reported in Sub Saharan Africa and South Asia, there is a gap in knowledge of impact of GBV and mental distress and other related mental disturbance in developing countries. Studies in the Global North clearly indicate a relationship between GBV and mental distress among women. A study done on lifetime prevalence of GBV and relationship with mental disorders and psychosocial function showed that for women who experienced three or four types of GBV, the rates of mental disorders were 77.3 percent. About half of these women experienced anxiety, depression and substance abuse; about a third experienced active suicidal ideation and attempts. Similarly, studies have shown that lack of emotional support post GBV increased the occurrence of mental distress by half and was also a factor for suicide.

There is a bi-directional relation between GBV and mental health. Women experiencing abuse are at a greater risk of mental distress. Having a mental health disorder makes one more vulnerable to abuse, particularly for individuals with depressive disorders. As a result, people with GBV are burdened by social, psychological and economic consequences which lead to poor quality of life. It is therefore important to know more about the prevalence of mental distress among women who experienced gender based violence, especially in developing countries, where other psychosocial and economic drivers further compound the problem.

Adolescents

According to the WHO, young women aged 15 to 19 are the most affected by GBV, especially IPV. By the time they are 19, almost 1 in 4 girls (24 percent) who have been in a relationship, have already been physically, sexually or psychologically abused by a partner. Adolescent girls, especially those living in extreme poverty, face high rates of violence, including interpersonal violence, transactional sex and age-disparate relationships.

A recent global analysis showed rates of physical and sexual intimate partner violence are 8-10 percent higher among adolescent girls compared to adult women aged 20-64 years. In Africa, rates of lifetime exposure to GBV among adolescent girls can be as high as 30-48 percent, with mortality associated with GBV being more pronounced in conflict settings. Given that 60 percent of the population in Pakistan is under 30, with similar risk factors, it is important to understand the causation in our setting – why adolescent girls are more vulnerable to GBV compared to boys and older women; and how social protection can be tailored to protect them.

Adolescence is also a critical time for prevention of mental illness. The WHO estimates that half of all mental illnesses begin by the age of 14, and three-quarters by 20. Neuropsychiatric conditions are the leading cause of disability. Suicide is the second-leading cause of death among 15-29-year-olds, globally; some studies suggest that it is the leading cause of death for this age group in Pakistan. Thus, approaches that might prevent or mitigate both GBV and mental health problems in this age group are essential.

Other groups

While most victims of GBV and IPV are women, high rates of violence are also experienced by other groups, including sexual and gender minorities, people with disabilities, migrants, and people from marginalised ethnic or indigenous groups. This group is also more vulnerable to mental health disorders. The relationship between IPV and mental health therefore is complex. Exposure to violence in childhood or adulthood increases the likelihood of developing a range of mental health problems, suicidal ideation and attempts. The presence of mental health problems also makes individuals more vulnerable to experiencing violence. Children exposed to violence in any form are at high risk of additional forms of abuse and neglect. Experiencing abuse or being exposed to GBV in childhood greatly increases the risk of both experiencing and perpetrating GBV as an adult. Associations between mental health problems and experiencing or perpetrating violence, especially in the presence of a substance abuse disorder, appear to occur across the life course and relate to both the onset and the course of mental health problems.

Interventions

GBV and mental health issues clearly have a complex and intertwined relationship, deeply rooted in psychosocial, economic and cultural determinants. Any and all systemic and large scale interventions must occur at primary, secondary and tertiary levels, both for GBV prevention and mitigation of risks for the mental health of GBV victims and survivors. It would be helpful to develop interventions based on the principles of: 1) accessibility, where barriers in accessing care are removed where feasible; 2) effectivity, where the interventions are evidence based in improving mental health outcomes; 3) sustainability, where the interventions aim to improve long-term mental health outcomes; and 4) equality and justice, where each patient is treated equally and with respect.

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