Dr. Lluïsa Garcia Esteve: “Sexual violence causes short-, medium- and long-term illness”

Interview with Dr. Lluïsa Garcia Esteve, psychiatrist and president of the Commission on Domestic and Gender-Based Violence

What is the situation with sexual violence in Catalonia at the moment?

Sexual violence is much more visible at the moment.  There is a different social awareness and, moreover, people are beginning to understand that sexual violence is not simply something that happens to some women in vulnerable situations, but that it is a phenomenon that all women can suffer.  The aggressors, who are always men, can be close friends or relatives.  Before, the rapist or abuser was a distant figure, and now we realize that it can be the husband, a friend, or a relative of the victim… 25% of women are victims of sexual assault at some point in their life. The sexual abuse of minors is also a phenomenon that we are seeing more and more of and this worries us. We also need to bear in mind that 85% of all cases of sexual abuse of minors take place in a family setting.

25% of women are victims of sexual assault at some point in their life. The sexual abuse of minors is also a phenomenon that we are seeing more and more of and this worries us

What is the difference between rape and sexual assault?

It is important to differentiate these two concepts. Rape is a type of sexual assault. Rape involves vaginal, anal or oral penetration with a sex organ or even an object; and sexual assault does not always involve penetration. It can involve unwanted touching or can take the form of cyber sexual assault, for example. Sexual abuse includes any behaviour perpetrated with a certain degree of deceit or threat by someone in a position of superiority or authority over the victim.    Another type of sexual assault is female genital mutilation. These are operations that remove the clitoris and/or all of the external female genitalia, especially in the Muslim religion. Forced marriage is another type of sexual abuse.

The Hospital Clínic Commission on Domestic and Gender-Based Violence was created 30 years ago. What is your assessment of this?

The overall picture is undoubtedly positive, and this is thanks to the professionals involved and the Hospital’s management.  Thirty years ago, the healthcare staff in the Hospital Clínic’s A&E Department started to be concerned about how to treat women exposed to gender-based violence.  At that time, not a lot was known about it and it wasn’t really talked about much.  It became apparent that a comprehensive and adequate response was needed.  We wanted to address the physical injuries (burns, wounds, blows, bruises, hair loss, etc.), and also the abusive situation itself, since we know that a person's health is also affected after an assault. Exposure to violence undermines a woman’s health and puts them at risk, and sometimes at risk of death.

It was 30 years ago that the staff, mainly from the following areas - A&E, nursing, social work, internal medicine, psychiatry, surgery, gynaecology, and infectious diseases – created this Commission, and even the Head of A&E at that time, Dr. Millà, got involved in the Commission and was its president until he retired. This impetus by leading healthcare professionals received institutional recognition from the management and a large part of the organization. We still have this recognition and are grateful for it.

But it is not possible ‘combat’ this scourge on your own…

The Commission started to work in a network with a model that is careful not to revictimize victims, validating the discourse, paying attention to the needs that may arise. Very soon, the Commission’s work focused on creating a comprehensive protocol on sexual violence, which can be offered 365 days a year, 24 hours a day for the city of Barcelona. After some time, the Commission started to work with external agents such as the Institute of Legal and Forensic Medicine and the Mossos d’Esquadra victim support groups, the Department of Justice’s victim support offices and several associations that provide legal advice to these women.  These are key agents in the entire process.  Moreover, we have been involved right from the start in the ‘Barcelona against gender-based violence circuit’ led by Barcelona City Council and the Barcelona Health Consortium, and we wanted to get involved in the community network.  

The key, however, lies in the physical and psychological scars that these women may suffer…

In 2004, psychiatry professionals from the Commission told us that the emergency care was very complete, but that there was no proper follow-up after the assault, once the woman had been discharged. This is how the psychiatric and infectious disease follow-up programmes were created. Mental health problems are the most frequent consequences in women who have been sexually assaulted. The symptoms can appear at the time of the assault itself or else weeks or even months later. We know from our own study that 60% of women who have been sexually assaulted will present psychological symptomatology requiring intervention one month after the assault. There is a great need for research to be promoted in this area, so as to better understand this situation and the therapies that should be applied to enable the victim’s psychological health to recover.

Mental health problems are the most frequent consequences in women who have been sexually assaulted. The symptoms can appear at the time of the assault itself or else weeks or even months later

Sexual violence causes other illnesses, so…

Sexual violence causes short-, medium- and long-term illness. Sexual assaults are a threat to integrity and are a traumatic experience that leads the body to react to intense stress, causing different symptoms, dysfunctions that can be mild or severe. These include:  post-traumatic stress disorder, depression, anxiety, substance abuse, sleep problems, self-harm, etc.  Sexual assault can lead to a significant disruption in a person’s everyday life with changes in: habits, relationships with others, daily activities; and changes in a person's health and quality of life, their occupational, social and personal functioning, etc.  Sexual assault must be assessed and both psychological and psychiatric treatment provided, because it must be dealt with urgently, quickly, and the consequences and impact on the person's health and functioning need to be evaluated, since they can cause a high level of dysfunction, suffering and disability.

Is there more demand for help now than before?

Now there is more social awareness that the victim of a sexual assault should seek professional help in order to regain their health. Women who have experienced a traumatic situation tend to avoid reliving the situation and, therefore, avoid asking for help. For them, going back to the hospital means recalling that dark chapter in their life.  In our programme to help people recover from psychological scars, we have created a proactive circuit to ensure patients are linked to it as quickly as possible and to prevent the consolidation of post-traumatic symptoms.  Thirty per cent of sexually assaulted victims treated at the Hospital Clínic are linked to follow-up programmes straight after the assault.  

How has COVID-19 affected these women?

It is clear that the lockdown in 2020 led to fewer women going to the A&E Department. However, the COVID-19 pandemic changed the profile of the assaults. Before, the assaults were committed in a context of discotheques, parties, nightlife, etc. During the lockdown, on the other hand, there was an increase in the percentage of assaults in the context of intimate partner violence taking place at home.  Now, without the curfew and with few restrictions, on average we are again treating 8-10 women per week in the A&E Department.

Are the health authorities really aware of this problem? Do they believe it? 

The health authorities have supported and recognized the programme. Former minister Vergés’ first act after she was appointed was to go to the Hospital Clínic to see first-hand what the sexual violence support team in the Catalan Department of Health were doing. The Catalan Department of Health has financed part of our programme, certainly, and also recognized and accredited our emergency care and follow-up programmes as best practice in treating gender-based violence in the field of health.

However, we still need to improve the care provided and the treatment to help victims regain their health, especially their mental health, as this is compromised after an assault.  We need a more global vision of the entire health and legal process, in order to provide a suitable response in terms of health, training and research and to create specialized health services and teams that work in collaboration with the specific networks that deal with gender-based violence.  We need a joint national strategy, a national plan, with all the agents involved.