Violence directed against a person of another gender is a problem that has been with us throughout recorded history. Only recently has this problem been recognized, starting with the 1993 Human Rights Conference that declared violence against women to be an abuse of their human rights.

Since then, the United Nations Declaration Against Violence Against Women (1993), the International Conference on Population and Development (1994), the Fourth World Conference on Women (1995), and the Inter-American Convention to Prevent, Sanction and Eradicate Violence (1995) have all publicly denounced this as an international problem.

The majority of world governments have ratified these declarations and are now incorporating them into their national policies. The UN General Assembly has officially designated November 25 as the International Day for the Elimination of Violence against Women.

A Case Study in Lima, Peru

Angela is a 27-year-old housewife in Lima, who was in an abusive relationship.

"I would have to sleep with my husband just to get any money for daily necessities. I practically had to sell my body. I thought it was just my fate, because my father severely abused my mother. But I have just made an accusation against him, and he signed a document holding him accountable for providing me with financial support. Now I have rights and know that there are institutions that defend abused women. I'm still living in the same house, but my husband does not abuse me anymore because he is prohibited by that document that he signed."

Angela recently completed 14 sessions with a Mutual Support Group in Peru assisted by the Pan American Health Organization (PAHO) and the Peruvian Ministry of Health, with support of the Government of the Netherlands. Support groups like this can prevent domestic violence by empowering women to escape from abusive situations. The sessions develop mutual support among the women suffering from abuse and enable them to regain their self-esteem and reassert control over their lives and those of their children. The Health Sector Response.

Although domestic or gender violence is globally recognized as a human rights abuse, in many countries of the Americas it is still not perceived or addressed as a public health problem. But according to the Center for Health and Gender Equity, in most countries the health care system is the only institution that interacts with almost every woman at some point in her life. This makes public health organizations the best point of contact to detect and initiate the correction of gender violence in the Americas.
Battered women are likely to interact with the health sector because of an increased incidence of physical and mental damage, as well as adverse reproductive health consequences, such as miscarriage or abortion. Unfortunately, most health providers have not been trained to recognize domestic violence risk or to collect information on the situation.

Studies show that health providers may see the same women multiple times for similar injuries without suspecting gender violence. Doctors have also been accused of being insensitive to the plight of female patients. "The demand for health services is so great, that there is no time to talk to the patients. In the diagnostic exams, the doctor only has time to look at the medical problems," said a Honduran health worker. Many women will not discuss violence unless asked directly. According to the Center for Health and Gender Equity, a 1998 Nicaraguan Demographic & Health Survey found that over one-third of the women who had been injured by their partners had never told anyone. Although 57 percent of the women had suffered injuries, only 13 percent ever received medical attention. Seven percent of women, reported having sought help at a health center or hospital for violence. Even then, most women did not admit to the cause of their injuries.

There are many factors that inhibit women from seeking help for abuse. The first are internal factors, such as gender beliefs and values, the fear of suffering increased aggression, or a lack of knowledge about their human rights and the laws against domestic violence. There is also the social shame of wife-beating and the desperate hope that their spouse will change.

External factors, such as the cost of medical exams and judicial proceedings, the bureaucratic process, the low quality of services, and lack of understanding, keep women silent. In addition ignorance about the process of confronting their abuser-or their economic dependence on him-stifle their initiative.

The factors that seem to catapult women into seeking help are the frequency and magnitude of the abuse or the growing realization that her children or family are at risk.

Gender Violence in the Americas

Although detailed data on the prevalence and nature of gender violence are still scarce, research shows that it is widespread throughout the Americas. The Panos Institute reports that gender violence causes more death and disability among women aged 15 to 44 than do cancer, malaria, traffic accidents, or war. A review of existing research compiled by the Center for Health and Gender Equity shows that between 10 and 50 percent of women-from a variety of studies and circumstances-have reported being hit or harmed by an intimate partner during their lifetime. Gender violence also differs from other types of social violence in that it is often based on the subordinate roles of women and girls within their families and communities. According to a l994 World Bank study, 50 to 70 percent of the abuse suffered by women in the Americas involved their partners or former partners-and a similar figure is reported worldwide.

Physical, Psychological and Sexual Abuse

A 1999 Population Report by the Center for Health and Gender Equity cited a Monterrey, Mexico, study showing that 52 percent of physically abused women were also sexually abused by their partners. A recent Nicaraguan study was even more dramatic, with 180 out of 188 physically abused women claiming sexual and emotional abuse as well.

Violence Against Women Not Reported

A study in the United States from a 1994 World Bank discussion paper showed that only 2 to 8 percent of sexual abuses against women were ever reported-compared to 62 percent of all assaults and 83 percent of all robberies. A large proportion of injuries and hospitalizations of women are also due to gender violence. The Forensic Institute of Bogota reports that during the 1980s, 20 percent of all reported injuries and 94 percent of hospitalized injuries to women were due to spousal violence.

Adolescent Pregnancies From Incest

A 1994 World Bank discussion paper cited a Costa Rican survey of adolescents in a shelter, where 95 percent of the pregnant girls 15 years old or younger were victims of incest. In PAHO's "Critical Route that Women Take to Deal with Intra-familiar Violence" study in Costa Rica, a victim of such sexual abuse recounted: "When I was in first grade, my uncle raped me, but when I told my aunt what he had done, she did not believe me. She said that I was a liar. And then she put me here in the Guadalupe Reformatory&where I was raised until I was 12 years old."

The Causes of Gender Violence

The Center for Health and Gender Equity believes that a framework of factors at the individual, family, community, and societal levels causes this violence against women. Factors that increase the likelihood of abuse on the individual level include the following:

• Being abused or witnessing marital violence in the home as a child;
• Having an absent or uninvolved father;
• Alcohol or drug abuse.

While the first two categories are considered environmental, both drug abuse and alcohol abuse are classified as diseases that can be treated by public health organizations. Even though gender violence can have a variety of root causes, it almost invariably results in physical damage and subsequent health problems. The best solution is early detection and treatment with the proper procedures.

Cross-Cultural Studies

Male control of wealth and decision-making within the family is a significant relationship factor that often leads to abuse. On the community level, the physical isolation of women and lack of social support-when combined with male peer groups that encourage and support violence-also increase the likelihood of violence against women. Finally, at the societal level, rigid gender roles and a "macho" concept of physical and psychological dominance often perpetuate violence against women.

"Violence against women is supported and/or reinforced by gender norms and values that put women in a subordinate position to men," said Claudia García-Moreno of the Evidence and Information for Policy unit of the World Health Organization (WHO).

A woman affected by violence in Panama recounted her story in a PAHO study: "The violence that I see most often is between husband and wife because the husbands are macho, they cheat on their wives, have women in the street and neglect their homes. When they come home, there are problems." "Cultural beliefs concerning violence in gender and sexual relationships are not only held at the individual level, but are re-enforced by the family, community and society level, including the media," said Garcia-Moreno. Boys and girls are socialized to adhere to cultural norms and values: Males are encouraged to be aggressive and sexually active, while females are taught to be submissive and resist sexual activity.

The Cost of Gender Violence

Gender violence incurs financial and social costs. Canada, as part of its national anti-gender violence campaign, estimated the cost of its domestic violence at US $1.1 billion per year, which included medical attention and lost productivity, according to a 1997 Inter-American Development Bank report.

The Center for Health and Gender Equity reports that violence against women and girls causes many immediate and long-term health problems such as injuries, death, or disability; a variety of chronic physical conditions; reproductive health problems; mental health disorders; suicide; drug abuse, and risky sexual behavior. Studies in the United States and Nicaragua estimate that abused women are two to three times more likely to need and use public health services.

There is also preliminary evidence that violence against women affects the health and development of their children. A recent study of abused women in Nicaragua showed that 63 percent of their children repeated a school year. Their children also dropped out of school four years earlier and were 100 times more likely to be hospitalized than the children of non-abused women. According to a 1996 National Research Council report, one-third of children who have been abused or exposed to parental violence become violent adults-and sexual abuse in childhood has been identified as a risk factor in males for sexual offenses as an adult.

Preventing Gender Violence

Gender violence is endemic in most developing countries, and both its perpetrators and its victims come from all classes, nationalities, and economic strata. While much of the research has focused on the personal characteristics of perpetrators, behavior is also influenced by society. Laws, cultural values, social structures, and local or family relationships help determine whether a person engages in violent behavior, and these social constructs can be changed.

Existing research shows that societies can be relatively free from domestic violence when there are supportive modes of community behavior and an active societal recognition of women. These include:

• The empowerment of women outside the home;
• Active community participation in addressing violence;
• Solidarity and advocacy by feminist groups;
• Sanctuaries from domestic violence.

To be successful, these interventions and programs should be integrated into the community and supported at the national policy level.

Community Efforts Involving Women, Men, and Youth

Effective interventions give more visibility to the problem and challenge the social norms and values that condone and encourage violence against women.

Some examples:

• "Zero Tolerance Campaigns" using mass media and education messages along with community sanctions to deter violence by publicly identifying and shaming abusers.
• "Take Back the Night" rallies bring together organizations, civic leaders, and individuals to protest violence against women and promote awareness of the attitudes, beliefs, and behaviors that perpetuate the violence.
• Marches in numerous cities in the United States, Latin America, Canada, India and Europe, stress the message: We march to demand that the perpetrators of this violence-the batterers, the rapists, the murderers-be held responsible for their actions and be made to change.
• Men can also become involved in speaking out against violence against women by helping change the social norms that perpetrate this behavior. Batterer Intervention Programs were initiated in the 1970s and are still the most common intervention method that focuses on group treatment.

According to Garcia-Moreno, interventions focusing on the children of abused women may be an important prevention strategy not only against domestic violence, but against violence in general. They can lead to the improved mental health and physical well-being of future generations. School programs for young children that help influence better gender relations, non-violent conflict resolution, and programs to teach parents how to raise children in a non-violent atmosphere can help heal society.

In the United States, the community-based approach, creating a network that ensures collaboration between all the groups of people that respond to women, has been so effective that it has been replicated in more than 100 communities during the last decade. With its national counterparts from the ministries of health and other public and private sectors, PAHO's Women's Health and Development Program (HDW) has developed an integrated model that has been put into practice in 70 municipalities in Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama, Peru, Bolivia, and Ecuador.

Addressing Gender Violence

PAHO's integrated model provides countries with a framework model to help each woman who is suffering from domestic abuse and eradicate the problem on a large scale. The model operates at three levels:

• At the community level creating networks;
• At the health sector level strengthening capacity to address gender violence and launching educational campaigns through the news media and other channels to cut tolerance of family violence;
• At the national level through coalitions that advocate for policies, legislation, and programs. Health Services

These are the initial detection points for women suffering from abuse. Health care providers are trained to screen women during primary and reproductive health care visits. They then apply protocols to assure quality service and data collection and are sometimes trained to collect judicial evidence.

Task Forces

These include PAHO, health ministries, and non-governmental organizations (NGOs), who assess the prevalence of violence by using information from the health providers, judicial system, police, and surveys. They apply the "Critical Route That Women Take in Dealing with Intra-familiar Violence" instrument developed by PAHO to identify community organizations, individuals, and resources to help women address their situation.

Health workers then use the task force information to mobilize community organizations and leaders to form support and service networks. These vary by community and may include police, judicial systems, community leaders, NGOs, women's organizations, schools, churches, and hospitals. The networks meet regularly to plan, implement, monitor, and coordinate activities that deal with the needs of victims and their families. They set up referral and information networks, training programs, and support groups.

Replication of this system at the regional and national levels should include representatives from local networks and national public programs, such as the ministries of health, women, labor, education, and welfare, as well as the courts. Networks can also advocate for policies, training, legislation, and resources to address domestic violence at the national, regional, and local levels.

PAHO and UN Agencies Promote "Lives Free From Violence"

PAHO and other United Nations agencies, along with regional and national institutions, are involved in an interagency effort to address gender violence through the "Violence Free Lives" Campaign.

As part of this campaign, "Symposium 2000: Gender Violence, Health and Rights," was planned for 2001 to mobilize the health sector's response to gender violence in the Americas, with over 250 key representatives of the ministries of health, ministries of women, NGOs, and donors invited to showcase national experiences and devise plans to strengthen the role of the health sector in caring for women affected by gender violence.

Local Organization Responses

There are many local organizations running successful programs to prevent and combat domestic violence:

• Peaceful Alternatives in Monterrey, Mexico, was the first association in the country to offer shelter to abused women and their children who suffer from domestic violence. It has provided psychological help, legal assistance, financial assistance, and medical services to 450 women, children, and adolescents. This year it is initiating a sensitization campaign about domestic violence via television, radio, and the press.

• St. Lucia Crisis Center in the Caribbean monitors cases of physical and emotional abuse toward women and incest toward girls. It has publicized the hardships of battered women and has protested the deaths of women due to domestic violence.

• Say No to Violence-Sister Theatre Collective in Jamaica uses drama to create public awareness about domestic violence and to help men and women learn to deal with it. The organization works with other non-profit groups to inform women of their rights and how to seek justice for domestic abuse.

• The CEFEMINA program in Costa Rica helps women leave abusive relationships by involving them in support groups and with the design and implementation of community housing projects. Sixty percent of the participants have escaped from violence after six months, at a cost of US$50 per woman per month. o Founded in 1988, CANTERA of Nicaragua has focused its efforts on the prevention of domestic violence through educating men to change their attitudes, value, and conduct.

• In 1998, Family Planning Association of Venezuela (PLAFAM) began offering medical treatment to battered women at its three family planning clinics in Caracas. All staff members have been trained to screen for domestic violence, and this is now a routine part of the health interview, which is conducted with every woman who attends a PLAFAM clinic. Counseling is also available for rape and sexual abuse victims.

• The Ecuadorian Center for Women's Advancement & Action (CEPAM) provides legal consultation, psychological support, shelter, and health care to women suffering from violence and their children, especially those from impoverished backgrounds. In addition, the center provides training to local organizations and outreach workers about advising women on their legal rights. CEPAM also advocates for better response to women's needs by the governmental legal institutions.

• Women police stations are a new initiative to make social services more accessible and responsive to women who experience domestic violence. The stations are staffed with multidisciplinary female teams equipped to respond to a variety of needs. The first one was set up in São Paulo, Brazil, in 1985, and now Argentina, Bolivia, Colombia, Costa Rica, Ecuador, Nicaragua, Peru, Uruguay, and Venezuela have their own as well.

Gender violence is different from other social violence, in that it happens in the privacy of homes and is often inflicted by loved ones or former partners. Most of the battered victims are women who have limited access to income or power and who are not likely to consult existing health services regarding gender violence. When they do consult these services, often it is only for the physical, mental, and reproductive health problems that were caused or aggravated by their situation.

Ultimately, violence against women is usually rooted in gender-based discrimination and, therefore, any attempt to address it should be linked to efforts that empower women. The Canadian Panel on Violence Against Women states that "it is abundantly clear that women will not be free from violence until there is equality, and equality cannot be achieved until violence and the threat of violence is eliminated from women's lives."

Preventing and addressing violence against women entails commitment from many sectors, as well as an integrated approach. Such a commitment and effort should focus on prevention as a basic human right and take a public health approach in which the health sector, battered women, and their advocates all actively participate. Even with all of this, it is an ambitious project.

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Dr. Marijke Velzeboer-Salcedo is coordinator of PAHO's program on Women, Health and Development. Julie Novick of PAHO's Public Information Office worked with her in researching and writing this story.

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