part of that strategy and plan of action. And fourth, states are obligated to train their health personnel in pain management, which is part of making the medications accessible in practice. If these steps were instituted across the world, millions of people would be saved immeasurable suffering.
Torture and Suffering in the Private Sphere
One way to expand the domain of rights is to reinterpret both what it means to act and how we understand causal responsibility. Inaction by the state should be seen as action when, as in Dolores’s case, the effects of such inaction are entirely predictable and preventable and we can identify reasonable measures for the state and other duty-bearers to take. Another way to expand rights and the responsibility of the state is to expand our consideration of assaults on dignity experienced in the so-called private sphere.
As I mentioned, in a narrowly circumscribed liberal paradigm of rights, freedom is seemingly exercised in a vacuum. Individuals in the liberal state are assumed to be “free” so long as the state does not force them to do something against their will. This is how we have traditionally thought about the right to be free from torture—as a shield from police (as in the Quijano case), as well as other state agents, including those in the health sector. Rights are conceived, in Roberto Unger’s words, as “a loaded gun that the right holder may shoot at will in his corner of town.” This view of rights in terms of isolated autonomy largely construes society and community as artificial constructs—rather than as processes through which our full identities emerge as individual human beings, as I suggested earlier.61
The idea implicit in such a view, that “every man’s home is his castle”—that rights only protect from infringements in the rigidly defined “public sphere”—is particularly inapposite for women and children who suffer the most direct violations of their rights within the “private sphere” of the home. For decades, feminists have pointed out that it is impossible to establish a true democracy in a society if each home is a dictatorship within which women have no rights. The “personal is political”—the “private sphere” is porous, and abuses of power exercised in the private sphere do not allow certain people to be genuinely free in any sphere of their lives. The same is true for how we raise children. The realization of children’s rights requires many public and societal changes. But it also fundamentally requires changing relationships within families so that decisions taken in children’s names or on their behalf are justified to them, and justifiable in terms of their “best interests.”62
Taking seriously the suffering of women, children, sexual minorities, and others requires a shift in the conception of rights and ensuing state obligations from the way in which they were set out in theories of the traditional liberal state. For example, both women and children are far more likely to face cruel, inhuman, and degrading treatment from domestic abuse than from police officers. In Tanzania, for example, three-quarters of children are subjected to physical or emotional abuse by the age of eighteen.63 Nearly a third of girls are subjected to sexual abuse,64 and not just in resource-poor settings, or the “developing world.” In the United States, in 2014, when it came to light that pro-football star Adrian Peterson had inflicted a “good old-fashioned whoopin’” on his four-year-old son, many rose to his defense as merely standing up for traditional authority, despite the sequelae of that punishment resulting in the child’s treatment in the emergency room.65 This kind of torture is often every bit as brutal as that suffered at the hands of state agents and, more often than not, children are witnesses to the violent abuse of their mothers or siblings—just as in the Quijano case, as Héctor’s mother and sister were forced to be. But in “private” settings—schools, homes, churches—the victims are often forced to see or even to live with the perpetrators, day in and day out.
International law, as well as domestic law in many countries, has evolved to address the obligations of states to protect people from abuses within the private sphere. For example, the UN Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), promulgated in 1979, and the Convention on the Rights of the Child, which was promulgated a decade later and as of 2014 has been ratified by every country except for the United States, South Sudan, and Somalia, transcend this rather artificial public-private divide and call for states to take responsibility for changing social practices that affect women and children, respectively.66 Subsequent normative development takes this evolution further, including extending obligations of nonstate (that is, private) actors.67 Moreover, in most countries there are national laws against domestic violence, at least against women if not children; and in some there are criminal prosecutions of perpetrators, and NGOs and agencies dedicated to helping survivors.
An enormous gap remains, however, between what the laws say and the pervasiveness of these forms of torture and abuse in practice.68 Just as with other forms of torture and inhuman treatment, the health impacts of intimate partner violence (IPV) are pervasive and irrefutable. Physical impacts of IPV include high rates of arthritis, chronic neck or back pain, chronic pelvic pain, stomach ulcers, hypertension, and frequent headaches.69 Some of the mental health effects include higher rates of depression, anxiety, post-traumatic stress disorder (PTSD), suicidal ideation, and substance abuse.70
Perhaps even worse, women and children who suffer from domestic violence too often believe they deserve the torture to which they are continually subjected. For example, in a global survey conducted in 2005, approximately two-thirds of women who had been subjected to domestic violence believed that it was appropriate for their husbands to hit or beat them for reasons that included not completing housework, disobeying their husband, refusing sex, and actual or suspected infidelity. A husband’s most common justification was suspecting a wife of being unfaithful.71 Further, women who are subject to abuse have little or no control over household resources, and little education.72 Therefore, their opportunity structures severely limit their ability to exert agency.
In the case of domestic violence against children, it is often not that the torture shatters an already formed world or a fully constructed sense of identity; rather, emotional, physical, and sexual abuse prevents them from forming a sense of themselves as full human beings in the first place. Sometimes such abuse relates to condemning or castigating a child’s expression of sexuality or gender identity as he or she is just beginning to have a sense of how that fits into his or her personhood. As I have stressed, we human beings construct the meaning of our lives every day through the small interactions we have with the people around us.73 When people or society mirror a confining or contemptible picture of themselves, it ends up, as British sociologist Steven Lukes notes, “imprisoning them in a ‘false, distorted and reduced mode of being.’”74
This process of internalizing domination is what leads so many girls—and members of sexual minorities and other marginalized groups—to see themselves as less than full human beings, with no claim to equal dignity. These are often the girls who then tend to believe they “deserve” to be beaten or neglected or abused in other ways as women; these are the members of sexual minorities who end up living under a cloak of shame and self-loathing. Recognizing this process of internalized domination, and its enormous health consequences, demands that our rights frameworks not only provide protection from abuse and access to entitlements, but also rethink the resources necessary to overcome internalized barriers and thereby create new opportunity structures for people to claim their dignity.
Changing laws and institutional practices is an important part of changing the common script through which we create our material and social realities as is ensuring equal access to endowments such as education and employment. But part of applying an empowering human rights framework to health and promoting a human rights culture must also entail changing the mirror that is held up to our private worlds, as those mirrors also create narratives for our lives and the conditions for developing our identities. Transforming our societies so that everyone can be accorded dignity requires actively working through both education systems and campaigns targeting popular culture to change how we see and relate to one
