When Maha, a nine-year-old Palestinian girl living in Gaza, visited a doctor to seek treatment for mental health problems she was told not to come back or she would likely be stigmatised for life, ruining her marriage prospects.
Despite high levels of post-traumatic stress disorder (PTSD), anxiety and depression in the Palestinian territory, mental health experts say families often avoid seeking help for their daughters for fear of wrecking the family reputation and the girl’s chances of finding a husband.
“There is a general stigma and lack of awareness around mental health,” said Bassam Abu Hamad, a public health consultant at Al Quds University in Gaza.
“People think mental health problems are something to do with the devil and supernatural forces. They think that people with such problems have lost their minds and are crazy.”
Hamad says Maha’s story highlights the worrying gaps in mental health services in Gaza, the cultural barriers girls face in accessing care and the urgent need for better training of general doctors.
“In Maha’s case, the doctor - a general practitioner - said that continuing to visit mental health services would affect her reputation and she would be stigmatised forever,” Hamad said.
Maha was originally taken to the doctor primarily for epilepsy, which in Gaza is treated as a mental health issue.
Her condition deteriorated during last year’s conflict in the territory after she had to run for her life when the family’s home in Beit Hanoun was bombed.
Maha, now 13, became very withdrawn and suffered repeated nightmares. It was only when her mother took her back to a doctor for an injury that she was finally referred to a specialist.
There are no figures for the prevalence of mental health problems in Gaza, but the World Health Organization (WHO) estimates the proportion of people suffering mild or moderate disorders rises to 15-20 percent during a humanitarian emergency compared to 10 percent outside a crisis.
Some experts say up to a third of the population may be affected by mental disorders after exposure to violence, the death of loved ones and the loss of homes, livelihoods and support networks.
WHO estimates the proportion of people with severe mental disorders including psychosis - which can cause hallucinations or delusions - rises to 3-4 percent during a crisis up from a baseline 2-3 percent.
Hamad said families are loath to seek mental health care services for sons as well as daughters, but the reluctance is more pronounced with a girl because of the potential impact on her reputation. “It’s a patriarchal community so women are judged more harshly,” he said.
WHO mental health officer for Gaza, Dyaa Saymah, said part of the reason girls with mental health disorders face particular stigma is due to the misconception that mental problems are strongly hereditary.
“People believe when a mother with a mental health illness gives birth she may pass this on to her baby. This is why they are afraid of getting married to a girl who has developed some sort of problem,” Saymah said.
Beliefs that mental health problems are hereditary - although there can be genetic links they are only one factor - mean families in Gaza may even hide away a relative with a psychotic disorder like schizophrenia to protect their daughters’ reputations.
Isolated
Experts say the protracted conflict in Gaza has triggered acute levels of psycho-social distress, especially among children and adolescents who make up nearly half the territory’s 1.8 million inhabitants.
Many are emotionally shattered after living through three wars in the past seven years, the last one being the most devastating.
Fighting between Israel and Palestinian militant groups killed more than 2,100 Palestinians during a 50-day war and caused massive destruction to homes and schools in the small coastal strip.
The United Nations estimated that 373,000 children required specialised psychosocial support.
Day-to-day suffering has been compounded by a blockade - imposed by Israel in 2007 after Hamas won elections - which has exacerbated unemployment, poverty and levels of depression.
Hamad said it was often harder for girls in Gaza to deal with traumatic experiences than boys because of cultural factors including severe restrictions on their movement which leave them far more isolated.
Boys can spend time with friends in the streets and play sport, but girls do not have similar outlets or opportunities to socialise, he said.
Hamad said mass displacement to overcrowded mixed shelters during last year’s conflict had been particularly stressful for adolescent girls because of the lack of privacy and sanitation.
Girls in shelters had to remain veiled at all times despite it being the height of summer, and many developed bladder-related problems because of a lack of separate toilets.
But mental health experts say there have been positive developments in Gaza. In particular, mental health services are being integrated into all primary health care centres across the territory which will help reduce the problem of people avoiding such services. In addition, counselling is provided across Gaza’s schools.
Hamad said the widespread suffering in last year’s war has also helped reduce the stigma. “Mental health is no longer just the problem of one person, it’s now the problem of everyone,” he said.
